We’ve discussed dangerous medication abbreviations on several occasions (see our Patient Safety Tips of the Week for June 12, 2007 “Medication-Related Issues in Ambulatory Surgery” and March 12, 2007 “10x Overdoses” and our September 2007 What’s New in the Patient Safety World column “The Impact of Abbreviations on Patient Safety”). The latter included an article (Brunetti et al 2007) which used the USP MEDMARX® database of medication errors submitted between 2004 and 2006 and found that 4.7% of the error reports submitted were attributable at least in part to use of abbreviations. Of the specific abbreviations implicated, “QD” in place of “once daily” accounted for 43.1% of all errors. That was followed by “U” for “units (13.1%), “cc” for “mL” (12.6%), “MSO4” or “MS” for “morphine sulfate” (9.7%), and decimal errors (3.7%). The article further points out that compliance with the Joint Commission “Do Not Use” list standard remains problematic and has actually worsened between 2004 and 2006.
ISMP’s list of error-prone abbreviations, symbols and dose designations is considerably more comprehensive that Joint Commission’s list of “Do Not Use” abbreviations. Joint Commission has not updated its list since it was developed in 2004, apparently because expanding the list has met resistance from hospitals. Joint Commission has, however, indicated it will look at the following abbreviations for possible inclusion on the list:
· The symbols “>” and “<”
· All abbreviations for drug names
· Apothecary units
· The symbol “@”
· The abbreviation “cc”
· The abbreviation “μg”
In reviewing a hospital’s “Do Not Use” abbreviation list for potential expansion, we found that about 4% of total orders had an abbreviation that appears on the ISMP list. However, about one in every seven verbal or telephone orders contained such an abbreviation.
We did a mini-survey of about 20 hospitals and could find none that use a list that goes beyond Joint Commission’s minimum requirements. We jokingly refer to this as an “unintended consequence” of Joint Commission. Obviously, hospitals fear they will be cited if Joint Commission finds an occurrence of an abbreviation from an expanded list. But it’s really no joking matter. There are many potentially dangerous abbreviations on the ISMP list that are being condoned.
So how does a healthcare organization go about expanding its “Do Not Use” list? The easy part is simply adopting all or part of ISMP’s list. The hard part is disseminating the new list, educating all appropriate healthcare workers about the list, auditing and providing feedback, and measuring the impact. That process may take several months so setting a “go-live” date for policy implementation is wise when adopting such an expanded list. And it is critical to remember that these abbreviations do not just apply to orders. They apply to all forms of documentation, including history and physical exams, progress notes, discharge summaries, CPOE screens, standardized order sets, and electronic medical records, etc. They also should apply to your entire organization, both inpatient and outpatient. In particular, you also need to make sure that all your computer order entry screens do not contain any of the abbreviations you are adding to your list. You would be surprised at how often these abbreviations appear in software provided by third party vendors.
The Madison Patient Safety Collaborative did a project on eliminating use of dangerous abbreviations and provides many useful lessons on implementation. Education, of course, is a necessary first step (though, like in many other QI projects, education by itself will almost never suffice to produce the improvement). The new list needs to be discussed at all relevant medical meetings (medical staff meetings, department meetings, medical executive committee, nursing and pharmacy meetings, and meetings for other providers plus your medical records staff and secretarial and office staffs). The list needs to appear in written communications to all (newsletters, etc.) and can appear on strategically placed posters around your facilities. Putting the list on a computer screensaver is also a very effective means of improving awareness. Incorporating the list in orientation or training of all new staff is important. Many organizations include it in their annual reorientation programs as well (a Power Point module on the topic can be made a required item at reorientation). A laminated pocket card with the list can be distributed to all staff (we currently distribute these to all new incoming residents).
More importantly, there are other interventions more likely to impact the issue. Some organizations developed separate medication order forms that use a “grid” to increase legibility and use separate columns for drug name, dose, frequency, route, indications, and other information. Some even use a laminated card as bookmark that separates the medication order section from the other order section, facilitating a prescriber seeing the list as they are writing orders. But perhaps the most important intervention is having a “hard stop” process in place to preclude any order written or given verbally that contains an abbreviation on the “do not use” list. The pharmacist would be required to speak directly with the ordering provider and require that the order be re-written (or redone verbally if re-writing is not practical). Also, importantly, use of computerize physician order entry (CPOE) can prevent use of such abbreviations (keeping in mind that, as above, you have carefully removed such abbreviations from all your computer software). But even if you are not yet at the CPOE stage, you probably have standardized order sets and you can design these with checkboxes, etc., that help order medications that won’t have one of the undesirable abbreviations.
Your monitoring process is also extremely important. Your Quality Improvement staff, medical records staff, and unit clerks can do spot checks of charts not only for orders but to make sure none of the documentation includes excluded abbreviations (also any charts you have selected for review via tracer methodology should be reviewed for unacceptable abbreviations). There needs to be feedback directly to ordering providers (from department chairs, VPMA’s, etc.). And like any good quality improvement project, you should graphically demonstrate your improvement with strategically placed charts. And perhaps the most important lesson from the Madison group is that your policy must have “teeth” (that is, you must enforce it).
However, you should also read an excellent review on abbreviations and acronyms in healthcare (Kuhn 2007) for an excellent discussion on the pitfalls and lack of success of both educational efforts and some enforcement actions.
Abbreviations remain a significant potential source for error and adverse patient outcomes. They need to be addressed at multiple levels. Medical records/coding personnel can look for them during their reviews. They can be a focus during Patient Safety Walk Rounds. They can be looked for during tracer methodology reviews of a patient during a hospitalization. Frankly, we like to make it a side exercise any time we are reviewing a chart for any reason. But when discussing the continued usage of these abbreviations, it is most helpful to be able to give some specific examples of cases in which use of these abbreviations clearly impacted negatively on patient care. As you’ve heard us say many times “nothing sells patient safety more than a good story”.
On a related issue, a recent ISMP Medication Safety Alert focused on “Misidentification of Alphanumeric Symbols in Both Handwritten and Computer-Generated Information”. They discuss those letters or numbers that resemble each other in handwriting or even on computer screens. Examples are the lower case l looking like the number 1. This is especially problematic when a medication name ends in “l” since that may be misinterpreted as a number “1” in front of a dosage, resulting in a much higher medication dose being given. The article provides a dozen examples of commonly misinterpreted alphanumeric symbols and offers potential solutions to minimize these, such as putting a slash through zeroes (to differentiate from the letter “O”) or a bar through the number “7” or the letter “Z” (to differentiate from the number “2”), block printing on lightly lined forms, use of tall man lettering, and including space between the drug name and the dose. They also note that, in general, lower case handwritten letters tend to produce more differentiation than upper case letters though clearly they provide numerous examples of problems interpreting lower case letters as well.
To the above ISMP comprehensive list we would also add the upper case “H” may occasionally be mistaken for a numeric “4” when handwritten.
ISMP. List of Error-Prone Abbreviations, Symbols and Dose Designations.
The Joint Commission. Official “Do Not Use” List.
Brunetti L, Santell JP, Hicks RW. The Impact of Abbreviations on Patient Safety. The Joint Commission Journal on Quality and Patient Safety 2007; 33: 576-583
Madison Patient Safety Collaborative
Eliminating Use of Dangerous Abbreviations
Kuhn IF. Abbreviations and Acronyms in Healthcare: When Shorter Isn't Sweeter. Pediatric Nursing. 33(5):392-398, September/October 2007.
ISMP. Misidentification of alphanumeric symbols in both handwritten and computer-generated information.
ISMP Medication Safety Alert. Acute Care Edition July 2, 2009