Transcript Communication tools

Medication safety
program
Prohibited Abbreviations
DO WE HAVE A PROBLEM?
What is the extent of the
problem?
How do errors happen?
Barriers & Safeguards
against Errors
Poor Lighting
Poorly Designed
Storage Facility
Multiple Demands
on Attention
Patient
receives
wrong drug
Poorly Designed
Drug Packaging
Poorly Designed
Order Forms
Inadequate Training
and Skills Mix
Swiss Cheese Model
James Reason, 1991
Latent
Failures
Studies
Although abbreviations in health care may
be efficient, their use comes at the expense
of patient safety.
 according to a study published in the
September 2007 issue of The Joint
Commission Journal on Quality and Patient
Safety.

The Problem
using Abbreviations are one of the most common
and preventable causes of medication errors.
Drug names, dosage units, and directions for use
should be written clearly to minimize confusion.
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Consequences of
Using Error-Prone Abbreviations

Misinterpretation may lead to mistakes that
result in patient harm

Delay start of therapy due to time spent for
clarification
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Top 10 Reported as causing harm
Generic Name
# of
Reports
Insulin
54
Morphine
43
Hydromorphone
32
Heparin (unfractionated)
19
Fentanyl
11
Warfarin
10
Furosemide
9
Dalteparin
7
Metoprolol
7
Ramipril
7
Accounted 199/465
harmful incidents. (ISMP
Canada; 2001-2005)
Wake up call
2006 JCI surveys shows 22% of
organizations non-compliant.
 Death of infant - morphine

Responsibility
Corporate P&T Committee
 Pharmaceutical Care
 Nursing Services
 Medical Services

Rx format
Spend some time
Addressograph
Allergy, height, weight & diagnosis
Generic name .
Legible handwriting.
Dose, route & frequencey
Signature & Badge #

Confusing?
 2.0mg
 .8mg
 Nitro
drip
 Diagnosis: CA
 Diagnosis USA
What is ?
1+1+1
 II tablets 2d PRN
 MWF
 Dimix/ Diamox
 CBZ
 HCTZ

HELP!!!
What is the extent of the
problem?
Tips
Identify and promote “physician
champions”
 The key is to prevent the abbreviations from
being written
 catch physicians before they depart from the
patient care area.
 Nurses may assist
 check abbreviations PRIOR

Implement “Do Not Use” List
The Institute for Safe Medication Practices
(ISMP) and the Food and Drug Administration
recommend that ISMP’s list of error-prone
abbreviations be considered whenever medical
information is communicated.
Complete list is located at:
www.ismp.org/Tools/errorproneabbreviations.pdf
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Short List of Error-Prone Notations*
The following notations should NEVER be used.
Notation
Reason
Instead Use
U
Mistaken for 0, 4, cc
“unit”
IU
Mistaken for IV or 10
“unit”
QD
Mistaken for QID
“daily”
*Comprises “do not use” list required for JCAHO accreditation
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Short List of Error-Prone Notations
Continued
Notation
QOD
Reason
Mistaken for QID, QD
Instead Use
“every
other day”
Trailing zero
(X.0 mg)
Decimal point missed
“X mg”
Naked decimal
point
(.X mg)
Decimal point missed
“0.X mg”
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Short List of Error-Prone Notations
Continued
Notation
MS
Reason
Instead Use
Can mean morphine “morphine sulfate”
sulfate or magnesium
sulfate
MSO4 and
MgSO4
Can be confused with “morphine sulfate”
each other
or “magnesium
sulfate”
cc
Mistaken for U
“mL”
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Short List of Error-Prone Notations
Continued
Notation
Drug name
abbreviations
(especially those
ending in “l”)
Reason
Instead Use
Mistaken for other drugs Complete
or notations
drug name
> or <
Mistaken as opposite
of intended
“greater than”
or “less than”
μ
Mistaken for mg
“mcg”
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Short List of Error-Prone Notations
Continued
Notation
Reason
Instead Use
@
Mistaken for 2
“at”
&
Mistaken for 2
“and”
/
Mistaken for 1
“per”
rather
than
a slash
mark
+
Mistaken for 4
“and”
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Short List of Error-Prone Notations
Continued
Notation
AD, AS, AU
Reason
Mistaken for OD, OS, OU
Instead Use
“right ear,”
“left ear,”
or “each ear”
OD, OS, OU
Mistaken for AD, AS, AU
“right eye,”
“left eye,”
or “each eye”
D/C, dc, d/c
Misinterpreted as
“discontinued” when
followed by list of
medications
“discharge” or
“discontinued”
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Other Good Practices

Drug name abbreviations can easily be
confused. Always write out complete drug
name.

Apothecary units are unfamiliar to many
practitioners. Always use metric units.
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Examples
Intended dose of 4 units in patient history
interpreted as 44 units. “U” should be written
out as “unit.”
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Examples
Intended dose of “.4 mg” interpreted as 4
mg from medication order. Should be
written as “0.4 mg.”
24
Examples
“Potassium chloride QD” in medication order
interpreted as QID. Should be written as
“daily.”
25
Examples
Intended recommendation of “less than 10”
was interpreted as 4. “<” should be written out
as “less than.”
26
Examples
“QD” in advertisement should be written out as
“daily.”
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Examples
“U” in prominent professional journal article
should be written out as “unit.”
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Do Not Use Error-Prone
Abbreviations Even in Print

May still be confused

Perpetuates the impression that they are
acceptable

May be copied into written orders
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Recommendations for
Healthcare Professionals

Avoid ambiguous abbreviations in written orders, computergenerated labels, medication administration records, storage
bins/shelf labels, and preprinted protocols.

Work with computer software vendors to make changes in
electronic order entry programs.

Provide examples when educating staff on how using error-prone
abbreviations have led to serious patient harm.

Provide staff with ISMP’s list of error-prone abbreviations.

Introduce healthcare students to the list of error-prone
abbreviations.
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Recommendations for
Pharmaceutical Industry

Review existing drug labeling and packaging as well as new drug
applications for use of error-prone abbreviations.

Eradicate use of ambiguous abbreviations in product advertising
(both in graphics and text).

Check for error-prone abbreviations in all communications
vehicles, including slides, promotional kits, and sales staff
training materials.

Include ISMP’s list in corporate editorial style guidelines.

Incorporate list into software and medical device design.
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Recommendations for Medical
Communications/Publishing Professionals

Make “do not use list” of notations as part of
publishing style manuals and internal style guides for
clinical writing.

Add the list of error-prone abbreviations to
instructions for journal authors.

Review all internal and external communications
products for ambiguous abbreviations.

Eliminate error-prone abbreviations in company-wide
educational and training sessions.
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Other Resources
For more information and tools to help
promote safe practices, visit:
www.ismp.org/tools/abbreviations
or
www.fda.gov/cder/drug/MedErrors
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The pweor of the hmuan mnid
Aoccdrnig to a rscheearch at Cmabrigde
Uinervtisy, it deosn't mttaer in what oredr the
ltteers in a wrod are. The olny iprmoetnt tihng is
taht the frist and lsat ltteer be at the rghit pclae.
The rset can be a total mses and you can sitll raed
it wouthit porbelm. Tihs is bcuseae the huamn
mnid deos not raed ervey lteter by istlef, but the
wrod as a wlohe.
Amzanig huh?
Thank
You