Error prone abbreviations
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Error Prone Abbreviations. To Abbreviate or Not to Abbreviate?. Abbreviations are often used when writing orders to indicate dosage times, frequencies, routes, and other information about the med.

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Error Prone Abbreviations

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Error prone abbreviations

Error Prone Abbreviations


To abbreviate or not to abbreviate

To Abbreviate or Not to Abbreviate?

  • Abbreviations are often used when writing orders to indicate dosage times, frequencies, routes, and other information about the med.

  • However, the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) recommends not using abbreviations when writing med orders because of the high amount of errors that have occurred related to use of abbreviations.


Can you think of any complications related to misinterpreted abbreviations

Can you think of any complications related to misinterpreted abbreviations?


Jcaho steps in

JCAHO steps in…

  • JCAHO developed the official “do not use” list of abbreviations in 2004.

  • These abbreviations should NOT be used when documenting med orders or other medication information.


Jcaho s do not use list

JCAHO’s “Do Not Use List”


Abbreviation q d or qd

Abbreviation: q.d. or QD

  • Meaning: Every Day

  • Misinterpretation: q.i.d (four times daily)

  • Correction: Daily


Abbreviation u or u

Abbreviation: U or u

  • Meaning: Unit

  • Misinterpretation: The number zero causing a tenfold overdose. (For example, 10u could be seen as 100!)

  • Correction: Unit


Abbreviation q o d or qod

Abbreviation: q.o.d. or QOD

  • Meaning: Every Other Day

  • Misinterpretation: q.d. or q.i.d.

  • Correction: Every Other Day


Abbreviation ms mso 4 mgso 4

Abbreviation: MS, MSO4, MgSO4

  • Meaning: Morphine Sulfate and Magnesium Sulfate

  • Misinterpretation: Confused for one another.

  • Correction: Write out “morphine sulfate” and “magnesium sulfate”


Abbreviation iu

Abbreviation: IU

  • Meaning: International Unit

  • Misinterpretation: IV or the number 10.

  • Correction: Write out “international unit”


Abbreviation trailing zeros

Abbreviation: Trailing Zeros.

  • Example: 4.0 mg

  • Misinterpretation: 40 mg

  • Correction: 4 mg


Abbreviation lack of a leading zero

Abbreviation: Lack of a Leading Zero.

  • Example: .5 mg

  • Misinterpretation: 5 mg

  • Correction: 0.5 mg


Don t let this be you

Don’t let this be you…


Risky business

Risky Business…

  • An article entitled “Abbreviations: Speed or Risk?” on the website allbusiness.com, states that According to the Institute of Medicine (IOM) of the National Academies, there are more than 7,000 deaths a year due to medication errors. Mistakes can occur anywhere in the medication-use system, from prescribing to administering a drug in a variety of settings (hospitals, outpatient clinics, nursing homes, home care, etc.) Potentially confusing abbreviations are part of this problem.


A major cause for concern

A major cause for concern.

  • The use of abbreviations has received much attention as one of the major causes of medication errors.

  • The risk of misinterpreting an abbreviation is even greater with handwritten orders, as the handwriting may be illegible.

  • In addition to JCAHO, several other organizations including the Institute of Medicine, American Society of Health-System Pharmacists, Food and Drug Administration, National Coordinating Council for Medication Error Reporting and Prevention, and American Hospital Association, warn that the use of inappropriate abbreviations may lead to confusion and communication failures.


Use caution when u use abbreviations

Use caution when “U” use abbreviations!

  • According to the website http://www.ismp.org/tools/abbreviations/ “One of the most common but preventable causes of medication errors is the use of ambiguous medical notations. Some abbreviations, symbols, and dose designations are frequently misinterpreted and lead to mistakes that result in patient harm. They can also delay the start of therapy and waste time spent in clarification.”


Not just handwriting

Not just handwriting…

  • Not only should you NOT handwrite dangerous abbreviations, you shouldn’t type them either.

  • Abbreviations in print could still be misinterpreted.

  • They could be copied onto handwritten orders.

  • And they may give them impression that it is okay to use such abbreviations, even when it’s not!


Some examples

Some examples:

The “4u” could be misinterpreted as “44”

instead of “4 units”


Examples

Examples:

Instead of taking one tab of KCl every day,

this patient could be getting it four times a day!


Error prone abbreviations

A PSA from http://www.ismp.org/tools/abbreviations


Reducing the use of unsafe abbreviations a study

Reducing the Use of Unsafe Abbreviations: A Study

  • An article titled “Educational interventions to reduce use of unsafe abbreviations” looked at the strategies used to reduce the usage of unsafe abbreviations at a level 1 trauma center at Detroit Receiving Hospital.

  • Six abbreviations were deemed as unsafe by the patient medical safety committees: 1) U for units, 2) µg for microgram, 3) TIW for three times a week, 4) ° the degree symbol for hour, 5) Trailing zeros after a decimal point, and 6) the lack of leading zeros before a decimal point.

  • Data on abbreviation use was collected by examining copies of patient’s order sheets which are sent from nursing units to the pharmacy for processing.


Reducing the use of unsafe abbreviations a study1

Reducing the Use of Unsafe Abbreviations: A Study

  • For 8 months data was collected during three 24-hour periods each month, with 7-10 days between each period.

  • A data collection sheet was developed to assist in documenting the number of opportunities for each unsafe abbreviation and the actual incidence of each.

  • Educational strategies were developed and began to be implemented a month after the start of the study.

  • These strategies included: inservice education programs for the medical, pharmacy, and nursing staffs; laminated pocket cards; patient chart dividers; stickers; and interventions by pharmacists and nurses during medication prescribing.


Reducing the use of unsafe abbreviations a study2

Reducing the Use of Unsafe Abbreviations: A Study

  • During the 8 month evaluation, 20,160 orders were reviewed, representing 27,663 opportunities to use a designated unsafe abbreviation.

  • Educational interventions successfully reduced the overall incidence of unsafe abbreviations from 19.69% to 3.31%


Reducing the use of unsafe abbreviations a study3

Reducing the Use of Unsafe Abbreviations: A Study

Results of the study.


In conclusion

In conclusion…

  • Medication errors related to the use of unsafe abbreviations is dangerous AND preventable.

  • Educating hospital staff on this matter is necessary to ensure that these errors do not occur.

  • JCAHO’s do not use list is just the minimum. There are other risky abbreviations that you should consider not using.

  • Check your agencies policy and procedure manual, they may have their own additional list of abbreviations not to use.


And lastly

And lastly…

When in doubt…

WRITE IT OUT!!!


Questions

Questions:

  • 1. What is the appropriate way to chart “every day”?

  • A. QD

  • B. q.d.

  • C. daily

  • D. QRST


Questions1

Questions:

  • 1. What is the appropriate way to chart “morphine sulfate”?

  • A. Morphine Sulfate

  • B. MS

  • C. MSO4

  • D. The pain pill


Questions2

Questions:

  • What is the appropriate way to chart four tenths of a milligram?

  • A. 4/10ths mg

  • B. 0.4 mg

  • C. .4 mg

  • D. 4mg


Questions3

Questions:

Who can name 3 abbreviations on the JCHAO do not use list?


Questions4

Questions:

Why is it dangerous to use the “do not use” abbreviations?


Questions5

Questions:

Where should you check to find out additional abbreviations you shouldn’t use at your agency?


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