Abbreviations: They're a definite threat to safety

'Do not use' list may not be enough

During 2006 surveys, about 22% of organizations were found to be out of compliance with The Joint Commission's "do not use" list of abbreviations, a requirement of the National Patient Safety Goals since 2004 — one of the most frequent non-compliance findings during surveys. Now a new study underscores that abbreviations pose a significant threat to patient safety.1

The study collected and analyzed data on nearly 30,000 medication errors resulting from abbreviations, which were reported to the United States Pharmacopeia's Medmarx, a national database for medication errors, from 2004 through 2006. Here are key findings:

  • The most common abbreviation resulting in a medication error was the use of "qd" in place of "once daily," accounting for 43.1% of all errors.
  • The other most common abbreviations resulting in medication errors were "U" for units, "cc" for mL, "MSO4" or "MS" for morphine sulfate, and decimal errors.
  • Eighty-one percent of the errors occurred during prescribing, while errors during transcribing and dispensing were much less frequent, representing only 14% and 2.9 % of errors, respectively.
  • Abbreviation errors originated more often from medical staff in comparison to nursing, pharmacy, other health care providers, or non-health care providers.

The study's findings suggest that even more abbreviations should be added to the "do not use" list. Candidates for an expanded list include drug name abbreviations, stem abbreviations (such as "amps," "nitro," and "succs"), µg (used for "mcg"), cc (used for "mL"), and dose scheduling ("BID," "TID," and "QID").

"I don't think that the study's findings are surprising to anybody. They mirror our own experience and the experience of organizations throughout the nation," says Kevin Tabb, MD, chief quality and medical information officer at Stanford (CA) Hospital & Clinics. "I think you would be hard pressed to find an organization at this point who would disagree with the findings."

After Stanford adopted all the required "do not use" abbreviations, an internal task force looked at whether any others should be included. The abbreviation for micrograms was added, and a "no abbreviation" policy was implemented for chemotherapy orders.

"We are constantly on the lookout for other abbreviations that have caused errors here that are not on the list. We haven't come up with anything else, but we're open to hearing about the experiences of others," says Tabb. "If there is something potentially dangerous that we have not picked up on, we sure would like to hear about it."

Habits hard to break

At Metro Health Hospital in Wyoming, MI, a list of symbols and acronyms that may not be used anywhere in the medical record was adopted several years ago. "This list is revised as new recommendations are given regarding abbreviations and symbols," says Cindy Allen-Fedor, vice president of outcomes management. "We monitor medical records to ensure unacceptable abbreviations are not being used."

The most difficult part of adopting the "do not use" abbreviation list was breaking old habits. "Many of the unacceptable abbreviations have been used by practitioners for several years," says Allen-Fedor. "It takes time and reminders to help practitioners unlearn routine behaviors."

It's easy to see that physicians who have been using the banned abbreviations for decades would have a tough time changing, but surprisingly, new physicians also have bad habits to unlearn. "We are amazed to find that newly graduated students continue to be trained in schools to use the abbreviations," says Tabb. "We still find gaps, which is very frustrating. So we are not only educating, we are undoing bad practices. And that's very difficult."

At the University of Kentucky, the "do not use" abbreviations are hard wired into the organization's computerized physician order entry (CPOE) system. "There are regular reminders on every chart. We perform chart audits and have excellent compliance," says Joseph Conigliaro, MD, MPH, director of the University of Kentucky's Center for Enterprise Quality and Safety. "These abbreviations and audits are reviewed by our pharmacy and our patient safety committee. As new recommendations are added, we make changes."

A full electronic medical record, which Stanford is currently implementing, has the "biggest bang for its buck," says Tabb. "That means more than just CPOE. It means including nursing and physician documentation, not just orders," he says. "We have had CPOE for many years, and about a year ago switched to full nursing documentation."

Compliance improved when nurses began using preapproved templates for documentation, which don't allow the use of unapproved abbreviations. "And in terms of orders, we really have not had problems with unapproved abbreviations because we've had order entry for many years," says Tabb.

But until now, the organization has not had a full electronic record including physician documentation. "All respiratory therapists, all orders, all pharmacists — everybody will be using it. While we don't believe that will be a complete panacea, it will go a long way toward helping us go toward the goal of zero use of unapproved abbreviations," says Tabb. "We expect to see a similar decline in their use for other pieces of the medical record."

The idea is to have multiple safeguards in place to prevent poor outcomes from occurring, instead of relying solely on education or a single piece of technology. "You want to combine a bunch of different things to be sure that the holes in the Swiss cheese don't line up, to prevent an accident from coming through," says Tabb.

[For more information, contact:

Cindy Allen-Fedor, Vice President of Outcomes Management, Metro Health Hospital, P.O. Box 9162122, Health Dr. SW, Wyoming, MI 49519. Phone: (616) 252-7068. E-mail: cindy.allen@metrogr.org.

Joseph Conigliaro, MD, MPH , University of Kentucky Center for Enterprise Quality and Safety, 800 Rose St., H106 - H108, Lexington, KY 40536-0293. Phone: (859) 323-5845. E-mail: jconi2@email.uky.edu

Kevin Tabb, MD, Chief Quality & Medical Information Officer, Stanford Hospital & Clinics, 300 Pasteur Dr., Stanford, CA 94305. Phone: (650) 723-4000. E-mail: ktabb@stanfordmed.org.]

Reference

  1. Brunetti L, Santell JP, Hicks RW. The impact of abbreviations on patient safety. Jt Comm J Qual Patient Saf 2007; 33:576-583.