This month’s issue of the Joint Commission Journal on Quality and Patient Safety has an article on “The Impact of Abbreviations on Patient Safety” . This appears to be the first attempt ever to quantify the adverse effects of using abbreviations.
The study used the USP MEDMARX® database of medication errors submitted between 2004 and 2006. It 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.
We previously gave some examples of significant problems with abbreviations in our March 12, 2007 and June 12, 2007 Tips of the Week. We have stressed that abbreviations on the “Do Not Use” lists should not be used anywhere in the chart. Many have felt that this applies only to orders but some of our examples demonstrate the dangers associated with their use anywhere in the chart (eg. H&P, progress notes, DC summaries, etc.).
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.
Surprisingly, on some pharmacy-oriented blogs on the web, there has been considerable negative opinion expressed about banning the abbreviation “QD”. Some have felt that banning such a “time-honored” abbreviation has had a downside at a time when we are trying to use once daily regimens more often (to promote patient compliance). Of course, any time we implement a “solution” for a problem, we are at risk of introducing unintended consequences. We need to remain very vigilant for unintended consequences. For example, how often might “once daily” in poorly legible handwriting be interpreted as “twice daily”? We suspect that does happen but probably a lot less commonly than mistaking a “QD” for a “QID”.
Update: See our July 14, 2009 Patient Safety Tip of the Week “Is Your “Do Not Use” Abbreviations List Adequate?”.