Section 1: Making the Case
The use of communication shortcuts such as abbreviations, acronyms, and symbols puts patients at risk. Changes need to be made so that all patients benefit from clear communication about their medications and treatment plans.
The use of abbreviations is a common practice in healthcare that is recognized to be unsafe. It will take more than an order writing policy or a list of abbreviations that are not to be used4 to change ingrained habits of communication. Practice change is a complex process. Time and a step-wise approach are needed to help healthcare providers adapt to new ways of communicating without using error-prone abbreviations. The first step is making a case for changing the way abbreviations are used.
When making a case:
- Establish the importance of the abbreviation issue using the literature.
- Define the problem in the local setting by gathering local evidence of current practices and reported problems related to abbreviation use.
- Determine the desired outcome of the initiative – what will be different about how abbreviations are used if the initiative is a success?
Abbreviations are a part of the culture of communication in healthcare
Historically, physicians, nurses, and pharmacists were taught to use Latin medical terms and their abbreviated forms when writing orders.5 The benefits of abbreviations seem obvious in today’s fast paced therapeutic environment – they are convenient, easy and quick to use, space saving, and hard to misspell.5
Abbreviations and acronyms are not universally understood
Some commonly understood abbreviations are a useful part of practice (e.g., ‘a.m.’ for morning or ‘AIDS’ for acquired immunodeficiency syndrome). Other abbreviations lead to misinterpretation of instructions if they have multiple meanings or are not understood by all healthcare providers (e.g., OD can mean ‘once a day’ or ‘right eye’ or ‘overdose’).5,6,7
Use of abbreviations is widespread
Abbreviations are found in medical treatment orders, prescriptions, medication administration records, care plans, clinical notes about the patient, and instructions to patients.7,8,9 Free text entry fields in the electronic medical record are open to short forms of communication.8 Texting abbreviations and acronyms are increasingly being found in audits of health records.10
Students learn to use abbreviations early
Classroom and clinical educators need to be aware of how abbreviation use is being modeled to students and new healthcare providers. Discourage students from using abbreviations and texting acronyms in their assignments and in all forms of professional communication including documenting in the patient health record.
Poor handwriting compounds the problem
Poor handwriting increases the risk associated with abbreviation use.11-14 In one study, 20 per cent of orders with error-prone abbreviations were deemed illegible.11 When illegible handwriting was a contributing factor to a medication error, the order often included an abbreviation.12, 13 Error-prone abbreviations can also be introduced when a verbal order is recorded or orders are copied onto a medication administration record.
Some abbreviations are more likely to result in errors
A small number of abbreviations were implicated in the majority of abbreviation-related errors reported to a national reporting system (Table 1).12
TABLE 1. TOP FIVE ABBREVIATIONS ASSOCIATED WITH ERRORS
|Abbreviation||Percentage of abbreviation-related errors|
|MS04 or MS||10%|
|Leading or trailing zeros||4%|
Adapted from Brunetti et al., 200712
Research documents the issue and impact of abbreviation use
Evidence from research on the impact of abbreviations will be useful in building a case for an abbreviation initiative. A summary of some of the research documenting the issues with abbreviation use is provided in the Resources at the bottom of this page.
Patient safety organizations urge limiting abbreviation use
Many patient safety organizations (Table 2) have identified specific error-prone abbreviations and recommend that steps be taken to limit or prohibit their use. Accreditation Canada has a Required Organizational Practice related to dangerous abbreviations.4 Most of these resources refer to the use of abbreviations in medication orders. However, there is a much broader scope of situations and types of documentation where the use of error-prone abbreviations should be eliminated.6 (Table 3)
TABLE 2. PATIENT SAFETY ORGANIZATION RESOURCES
|Accreditation Canada||Dangerous Abbreviations Required Organizational Practice4|
|Institute for Safe Medication Practices Canada (ISMP Canada)||Do Not Use Dangerous Abbreviations, Symbols and Dose Designations15|
|Institute for Safe Medication Practices (ISMP)||List of Error-Prone Abbreviations, Symbols and Dose Designations16|
|The Joint Commission||Facts about the Official ‘Do Not Use’ List17|
|National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP)||Dangerous Abbreviations15|
|Australian Commission on Safety and Quality in Healthcare||Recommendations for Terminology, Abbreviations and Symbols Used in the Prescribing and Administration of Medicines19|
TABLE 3. TYPES OF COMMUNICATION WHERE ERROR-PRONE ABBREVIATIONS SHOULD BE ELIMINATED20
Pre-printed prescriber order sets
|Transcribed orders||Verbal orders
Medication administration records
Medication reconciliation – best possible medication history form
|Clinical communication||Progress notes
Emergency department visit records
Discharge and transfer summaries
Protocols and care maps
|Electronic medical or health records||E-prescribing or computerized prescriber order entry
Free text entries in encounter notes or prescription notes
|Published medical information||Style guidelines include abbreviations not to be used
|Pharmaceutical industry communications||Promotional advertising including graphics and text
Training materials, presentations
Packaging and labelling
|Education institutions/continuing education programs||Instructional materials
Computer systems used in laboratories or practice settings
Communications with or instructions to students in small teaching groups
In addition to evidence from the literature, an improvement initiative is more likely to be successful if it addresses a documented problem in the local setting. For example, is there an error-prone abbreviation that is frequently used or that has been a contributing factor in patient safety incidents? How are abbreviations used in high risk situations where misinterpretation could have significant consequences for the patient? More information about specific high risk situations – high alert medications, abbreviated medication names, and pediatrics – can be found here.
To focus the abbreviation initiative, define the local problem and relate it to what is known about the impact of abbreviations from the literature. This will help build a case for an executive sponsor (Engaging the Right People). Some questions that can be used to guide collection of information to help define local practice patterns are presented in Table 4. Sources of information about abbreviation use may include:
- Patient health records – particularly medication and treatment orders, clinical notes, and records of treatments given (e.g., medication administration records)
- Order sets (e.g., pre-printed forms or electronic documents)
- Reports of patient safety incidents or close calls involving abbreviations
- Medication or treatment orders with abbreviations that require clarification with the prescriber
Gather information by reviewing records from a specific time period in the past, or by noting abbreviations as they are currently being used. Although data from the local setting will be most relevant, consider trying to find information from similar organizations or programs if possible. Comparative data may also be found in the literature.
TABLE 4. QUESTIONS TO HELP DEFINE LOCAL PRACTICE PATTERNS
- What abbreviations are most commonly used in the setting?
- What abbreviations are used with high alert medications (e.g., insulin, warfarin, narcotics)?
- What abbreviations have been implicated in patient safety incidents?
- Who is using abbreviations (e.g., doctor, nurse, pharmacist, other healthcare provider)?
- How are abbreviations being used (e.g., to order treatments, document patient progress, transcribe treatment orders, give instructions to patients)?
- What abbreviations are commonly used for each purpose?
- What is the impact of abbreviation use (e.g., orders need to be clarified; abbreviation results in a close call or error, such as a transcription error or patient receiving an incorrect dose of medication)?
What is the desired outcome of the initiative?
The desired outcome of the initiative describes what the future state of abbreviation use in the local setting will look like if the initiative is successful. A goal will be more likely to be achieved if it is focused on a local problem demonstrated to be important. Goals should be SMART:
- Realistic and relevant for the setting, and
- Time-bound (a time frame to achieve the outcome is established)
More in-depth review of the literature from which the summary information was abstracted. Includes a complete reference list for the Abbreviations Toolkit.
Table summarizing selected research that documents the problems with abbreviation use in healthcare.
Overview of the issues when abbreviations are used to communicate about insulin, anticoagulants, digoxin, and narcotics.
Overview of the issues association with abbreviating medication names, using acronyms, and confusion with suffixes used to distinguish between formulations.
Overview of issues related to using abbreviations to communicate about medications in pediatrics and specific concerns related to correct dosing of liquid preparations.