Abbreviations formally linked to medication errors

If anything, numbers probably understate the problem

In one of the first formal studies linking the use of abbreviations to medication errors, researchers reporting their findings in the Joint Commission Journal on Quality and Patient Safety state that 4.7% of the 643,151 errors reported to the Medmarx program from 2004 through 2006 were attributable to abbreviation use.1

What's more, says lead author Luigi Brunetti, PharmD, clinical assistant professor, Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, and clinical specialist in internal medicine at Somerset Medical Center, those numbers may only scratch the surface in illustrating the extent of the problem.

"Even though only 0.3% of the errors ended up in patient harm, that's a huge underestimate," he asserts. "We looked specifically at what was reported as patient harm. We did not look at length of stay, or whether, for example, inappropriate doses had an effect on that. Then, there are antibiotics; did we actually help in the emergence of resistant organisms by [over]-dosing?"

Making the issue real

Brunetti says that putting numbers to the issue is, in and of itself, significant. "No. 1, abbreviation errors do happen, and this is one of the first studies that puts numbers behind them; having 5% of errors associated with abbreviations — that's significant." In addition, he says, "when people see real numbers that means more than when someone simply says, 'Abbreviations may cause errors.'"

Also of interest were the abbreviations that most commonly resulted in error. They included:

  • The use of "QD" in place of once "daily," which accounted for 43.1% of all errors;
  • The use of "U" for units (13.1%);
  • The use of "cc" for "ml" (12.6%);
  • The use of "MS04" or "MS" for "morphine sulfate" (9.7%); and
  • Decimal errors (3.7%).

"Many of the abbreviations we found problems with were on [The Joint Commission's] 'do not use' list," Brunetti observes, noting that this "definitely reaffirms" the importance of observing the list. In fact, only the use of "cc" instead of "ml" is not part of that list.

"Even though it has been out since 2004, we are still having problems with compliance," he notes. In fact, according to The Joint Commission, compliance dropped from 75.2% to 64.2% between 2004 and 2006. However, notes Brunetti, "compliance numbers may be down due to a reduction in reporting."

Improving reporting

Reporting, he continues, is one of the major areas that must be addressed to more effectively reduce medication errors. "In looking at the Medmarx data, we learned that about 40% of errors that were reported have to do with abbreviations, but we do not have enough information to know which abbreviation," he explains. Improvement in reporting, he says, "starts with encouraging staff not only to report medication errors but to include as much information as they can." In order for a QI project in this area to have an impact, and to be significant, he explains, "you have to have a baseline to start at."

Engagement of leadership within each of the various health care professions is also critical, says Brunetti. "If the message comes, for example, from the medical director, it would carry more weight for physicians. If it comes from the director of pharmacy, it will carry more weight for pharmacists. Engaging leadership within each department is an excellent outlet for communicating what should and should not be done."

Accountability, says Brunetti, is another essential element in this overall strategy. "If you are a habitual offender, you should be held accountable for those actions," he asserts. "If you are a physician who keeps using the same abbreviations, the medical director should speak with you, and your privileges may be taken away or changed in some manner."

This does not mean, Brunetti emphasizes, abandoning a systems approach to errors. "In fact, ultimately it still is a system error," he says. "If you look at examples we highlighted in the paper, they started with an abbreviation error, but with each step it slipped farther through the cracks; all the 'holes in the swiss cheese' lined up."

If the error did not result in harm, he continues, that means it was caught somewhere in the process. "However, you still need to address the individual responsible," he insists.

And what of those staff members who eliminate errors? "Let people know they are doing a great job," Brunetti advises. "The term 'reward' does not necessarily mean monetary reward. Tell them errors have gone down; people like to hear they have made a difference in patient care. If you are able to show your staff that by complying [with the do not use list] they have reduced errors, that is very valuable."

Educate your staff

Finally, Brunetti says, you must educate your staff. "Education definitely isn't enough in and of itself," he says. "We can educate all we want, but we need accountability — we need to enforce that education. But education is important as well."

It's not enough, Brunetti points out, to simply tell your staff that abbreviations cause harm, or even to share the numbers behind studies like his. "That's fine and dandy, but it's really important to show case examples," he insists. "If you show specific instances where abbreviations caused errors that carries lot of weight — particularly if the example is institution-specific. If you have a doctor who's been used to doing something one way for 30 years and now you say he can't use that abbreviation, it will be hard to get buy-in, but if can you use a specific case example, they may think twice."

Besides collecting accurate data, the quality manager can play a major role in encouraging reporting, Brunetti suggests. "That's huge, because if things are not reported we won't know there's a problem," he says.

In addition, notes Brunetti, quality managers can encourage education programs that are specific to abbreviations and medication errors. "I don't see too much of this type of education going on," he laments. "When I go to a hospital, I see lot of [education about] treatment of MI, acidosis, and so forth. It would be nice to hold a meeting on patient safety and how variables affect medication errors into the mix."

[For more information, contact:

Luigi Brunetti, PharmD, Clinical Assistant Professor, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, New Brunswick. NJ. Phone: (908) 595-2645. E-mail: brunetti@rci.rutgers.edu.]

Reference

  1. Brunetti L, Santell JP, Hicks RW. The Impact of Abbreviations on Patient Safety. Jt Comm J Qual Patient Saf, September 2007; Vol. 33 No. 9: 576-583