Medication errors related to poor communications

The Joint Commission is warning that one of the major causes of medication errors is the ongoing use of potentially dangerous abbreviations and dose expressions. Risk managers should take action immediately to counter this pervasive problem, the Joint Commission advises.

In its latest issue of Sentinel Event Alert, the Joint Commission warns that patients can be harmed by illegible or confusing handwriting by clinicians and the failure of health care providers to communicate clearly with one another.

"Despite repeated warnings for more than 25 years by the Institute for Safe Medication Practices (ISMP) — and other organizations — about the dangers associated with using certain abbreviations when communicating medication information, the practice of using these dangerous abbreviations continues, increasing the potential for patient harm," according to the Sentinel Event Alert.

Symbols and abbreviations are frequently used to save time and effort when writing prescriptions and documenting in patient charts, says Darryl S. Rich, PharmD, MBA, FASHP, associate director of surveyor development and management with the Joint Commission. Rich lists these examples of Examples of especially problematic abbreviations:

• "U" for "units" and "µg" for "micrograms."

When "U" is handwritten, it can often look like a zero. The root cause of many sentinel events related to insulin dosage has been the interpretation of a "U" as a zero. Using the abbreviation "µg" is dangerous because when handwritten, the symbol "µ" can look like an "m."

• The use of trailing zeros such as 2.0 vs. 2, or the use of a leading decimal point without a leading zero such as .2 instead of 0.2.

The Joint Commission points out that the decimal point is sometimes not seen when orders are handwritten using trailing zeros or no leading zeros. Misinterpretation of such orders could lead to a tenfold dosing error.

To combat these errors, the Joint Commission says electronic prescribing is one of the best solutions. But such systems can be costly, so the Joint Commission makes these other recommendations that can be implemented with little or no budget:

• Develop a list of unacceptable abbreviations and symbols that is shared with all prescribers.

• Develop a policy to ensure that medical staff refer to the list, and take steps to ensure compliance.

• Establish a policy that if an unacceptable abbreviation is used, the prescription order is verified with the prescriber prior to being filled.

Those improvements are more than just a suggestion from the Joint Commission. Accreditation can depend on such changes, because the Joint Commission requires that medication orders have "the degree of accuracy, completeness, and discrimination necessary for their intended use," as found in Standard IM.3 in all manuals. Standard IM.3 also requires the use of standardized abbreviations, acronyms and symbols.

"Use of confusing and dangerous abbreviations is not consistent with the intent of this standard," the Sentinel Event Alert reports. Hospitals also are required to assess orders in the medical record for "presence, timeliness, legibility, and authentication," and see that "action is taken to improve the quality and timeliness of documentation that impacts patient care, " as found in IM.7.10 in the Comprehensive Accreditation Manual for Hospitals.

The Joint Commission reminds risk managers that the assessment should be done as part of the quarterly medical record review that hospitals undertake for record completeness and authentication. "As part of the review, Standard IM.7.10 clearly requires that legibility be addressed as well as completeness and authentication," the Sentinel Event Alert says.