Abbreviations May Save Minutes; Prohibiting Abbreviations May Save Lives

Just as a simple phrase, whispered by the first child playing the telephone game, can be completely misconstrued by the time the last player hears it, certain abbreviations used to convey medication orders may also be misinterpreted due to communication lapses. Unlike the game, the results are not amusing and may lead to serious medication errors.

In 2004, the Joint Commission introduced the “Do Not Use” list of abbreviations as part of its National Patient Safety Goals. However, “the emphasis on this matter, in addition to enforcement of this list, has dwindled since then,” said Luigi Brunetti, PharmD, clinical assistant professor at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey. Hospital compliance with the “Do Not Use” list of abbreviations fell from 75 percent in 2004 to 64 percent in 2006.

Knowing that the Joint Commission states that communication failures are one of the leading root causes of sentinel events and that abbreviation use hinders communication, Brunetti and his colleagues conducted a retrospective study to bring the “Do Not Use” topic to the forefront again by “putting numbers behind these errors to demonstrate their deleterious effects on patient safety.”

In The Impact of Abbreviations on Patient Safety, Brunetti and his colleagues evaluated 643,151 total medication errors reported between 2004 and 2006 to the United States Pharmacopeia MEDMARX® voluntary program, a national database for medication errors. Of these errors, 29,974 (4.7 percent) reports were due to abbreviation use and only 18,153 met inclusion criteria. The reports were subsequently broken down into recurring themes: 1) frequency of abbreviations associated with errors, 2) error outcome, 3) node where error originated, 4) staff involved and 5) type of error.

“In our study, which was the first of its kind, we found that the most common abbreviation resulting in a medication error was the use of ‘QD’ in place of ‘once daily,’ accounting for 43.1 percent of all errors, followed by ‘U’ for units (13.1 percent), ‘cc’ for mL (12.6 percent) and ‘MSO4’ or ‘MS’ for morphine sulfate (9.7 percent),” said Brunetti.

Other findings from the study include:

The top five abbreviations resulting in patient harm were “U,” “drug name,” “stem,” “TID” and “mcg.”
Most errors occurred at the prescribing node (81 percent).
Abbreviation errors originated more often from medical staff (78.5 percent) compared to nursing (15.1 percent) and pharmacy (4.2 percent).

The top abbreviation errors were:

“sc,” “HS” and “cc” for medical;
“IU,” “stem” drug names and “TID” for nursing;
“BID,” “ìg” and “d/c” for pharmacy.

The three most common types of abbreviation-related errors were prescribing (67.5 percent), improper dose/quantity (20.7 percent) and incorrectly prepared medication (3.9 percent).

“Although it’s not surprising that physicians are the most frequent offenders of the ‘Do Not Use’ list since they are responsible for initiating the majority of patient orders, it does place added responsibility on the nursing and pharmacy staff to contact the physician and clarify the order to keep patients out of harm’s way,” said Brunetti. “These health care providers already have enough to worry about during their busy day, especially if they are short-staffed.

“Abbreviations also contribute to further lapses and barriers in communication. When a nurse or pharmacist calls the physician regarding an ambiguous abbreviation, that call may not be returned in a timely fashion because he or she is getting so many calls about abbreviations. When the physician does return the call, it takes time away from patient care, just as it does when the nurse initiates the call. Likewise the pharmacist is spending time clarifying abbreviations, rather than profiling, putting orders in and getting medications to the patient’s bedside.

“This viscous cycle impacts patient care, but could easily be avoided by eliminating or minimizing the use of abbreviations,” continued Brunetti. “This behavior change could actually improve all health care providers’ time and resource utilization. It would require the identification of key hospital leadership figures within each discipline who would take on the task of implementing this change, as peer pressure exerted from within each respective profession would have a greater tendency of being accepted.”

Educating staff on the harmful effects of abbreviations is just one of many recommendations for improving communications, according to Brunetti’s study. If education is not enough, enforcement may be necessary by holding health care professionals accountable for infractions. Other suggestions include posting prohibited abbreviation lists on hospital ID badges, in patient charts, newsletters, an intranet site, computer screen savers and announcement boards, and introducing computerized physician order entry (CPOE) systems.

“Abbreviations should not be used even in CPOE systems,” said Brunetti. “Although many errors result from illegible hand writing and misunderstanding what abbreviation is written, errors can also result from misinterpreting what the abbreviation means; therefore, whether it’s hand written or in a CPOE system, an ambiguous abbreviation may still have the potential to produce an error.

“All health care practitioners know the importance of providing patients with quality care, but they also need to be aware that accurate communication, specifically not using abbreviations, in the health care environment is a critical component of patient safety.”