To Abbreviate or Not to Abbreviate? Abbreviations are often used when writing orders to indicate...
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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
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.
Slide 3
Can you think of any complications related to misinterpreted
abbreviations?
Slide 4
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.
Slide 5
JCAHOs Do Not Use List
Slide 6
Abbreviation: q.d. or QD Meaning: Every Day Misinterpretation:
q.i.d (four times daily) Correction: Daily
Slide 7
Abbreviation: U or u Meaning: Unit Misinterpretation: The
number zero causing a tenfold overdose. (For example, 10u could be
seen as 100!) Correction: Unit
Slide 8
Abbreviation: q.o.d. or QOD Meaning: Every Other Day
Misinterpretation: q.d. or q.i.d. Correction: Every Other Day
Slide 9
Abbreviation: MS, MSO 4, MgSO 4 Meaning: Morphine Sulfate and
Magnesium Sulfate Misinterpretation: Confused for one another.
Correction: Write out morphine sulfate and magnesium sulfate
Slide 10
Abbreviation: IU Meaning: International Unit Misinterpretation:
IV or the number 10. Correction: Write out international unit
Abbreviation: Lack of a Leading Zero. Example:.5 mg
Misinterpretation: 5 mg Correction: 0.5 mg
Slide 13
Dont let this be you
Slide 14
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.
Slide 15
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.
Slide 16
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.
Slide 17
Not just handwriting Not only should you NOT handwrite
dangerous abbreviations, you shouldnt 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 its not!
Slide 18
Some examples: The 4u could be misinterpreted as 44 instead of
4 units
Slide 19
Examples: Instead of taking one tab of KCl every day, this
patient could be getting it four times a day!
Slide 20
A PSA from http://www.ismp.org/tools/abbreviations
Slide 21
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) g 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 patients order sheets which are
sent from nursing units to the pharmacy for processing.
Slide 22
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.
Slide 23
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%
Slide 24
Reducing the Use of Unsafe Abbreviations: A Study Results of
the study.
Slide 25
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. JCAHOs 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.
Slide 26
And lastly
Slide 27
Questions: 1. What is the appropriate way to chart every day?
A. QD B. q.d. C. daily D. QRST
Slide 28
Questions: 1. What is the appropriate way to chart morphine
sulfate? A. Morphine Sulfate B. MS C. MSO4 D. The pain pill
Slide 29
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
Slide 30
Questions: Who can name 3 abbreviations on the JCHAO do not use
list?
Slide 31
Questions: Why is it dangerous to use the do not use
abbreviations?
Slide 32
Questions: Where should you check to find out additional
abbreviations you shouldnt use at your agency?