Study Indicates Abbreviations Pose Threat to Patient Safety

Although abbreviations are known causes of medication errors, the study-The Impact of Abbreviations on Patient Safety-is the first to examine the exact characterization and impact of these errors. The study collected and analyzed data through a retrospective review of errors resulting from abbreviations as reported to the United States Pharmacopeia's MEDMARX^®, a national database for medication errors, from 2004 through 2006.

The study found that nearly 5 percent of all errors reported to MEDMARX^® during this time period were attributable to abbreviations.  This analysis of nearly 30,000 medication error reports involving abbreviations suggests that health care organizations should consider additions to the "Do Not Use" list.  Candidates for an expanded list include drug name abbreviations (for example, PCN, DCN, TCN), stem abbreviations (amps, nitro, succs), µg (mcg), cc (mL), and dose scheduling (BID, TID, QID).

The authors of the study, led by Luigi Brunetti, Pharm.D., a clinical assistant professor at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, note that communication is the leading cause of sentinel events and that abbreviation use hinders communication. Sentinel events are unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof, that are tracked by The Joint Commission.

The study also characterizes error-prone abbreviations as preventable problems that are a logical area for improvement.

"Accurate communication in the health care environment is a critical component of patient safety. Our analysis of errors reported to the USP MEDMARX^® medication error reporting system confirms that abbreviation usage contributes to lapses in communication and may lead to patient harm," says Brunetti.

            The notable findings in the study include:

• 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.
• 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 percent and 2.9 percent of errors, respectively.
• Abbreviation errors originated more often from medical staff in comparison to nursing, pharmacy, other health care providers, and non-health care providers.
• The three most common types of abbreviation-related errors were prescribing, improper dose/quantity, and incorrectly prepared medication.

The study also found that in nearly 40 percent of the errors in which abbreviations were identified as the cause of error, the exact abbreviation was unidentified. The authors urge individuals and organizations reporting medication errors to include the key points that adequately describe the error, including the cause of the error, a brief description of the cause (in the case of abbreviations, which abbreviation), the contributing factors, the outcome, staff involved, and the point in the medication process when the error occurred in order to learn from the errors and improve patient safety.

            The Joint Commission Journal on Quality and Patient Safety, published monthly by Joint Commission Resources, features peer-reviewed research and case studies on improving quality and safety in health care organizations.  To subscribe to The Joint Commission Journal on Quality and Patient Safety, please call JCR Customer Service toll-free at 800.746.6578, or visit www.jcrinc.com