Abbr. pose patient safety risk
Friday September 14, 2007
A new study conducted by researchers at the Ernest Mario School of Pharmacy at Rutgers in New Jersey, concludes that while abbreviations within the medical community may be efficient, they also pose a threat to patient safety.

The study’s findings suggest the use of a “Do Not Use” list of abbreviations. It also calls on healthcare organizations to consider additions to the list, originally published by the International Centre for Patient Safety (ICPS).

The current list can be found here. The study itself was published in the September 2007 edition of The Joint Commission Journal on Quality and Patient Safety.

According to the ICPS, abbreviations are known to cause medication errors although the new study, titled The Impact of Abbreviations on Patient Safety, is the industry’s first look at the exact characterization and impact of those errors.

The study looks at medication errors made as a result of abbreviations as reported to a national database of medication errors in the United States between 2004 and 2006.

The study reveals that nearly five per cent of all medication errors registered in the national database are attributable to abbreviations. This accounts for nearly 30,000 individual patient safety incidents involving abbreviations.

According to Dr. Luigi Brunetti, the study’s lead researcher and a clinical assistant professor at the Ernest Mario School of Pharmacy at Rutgers, communication is the leading cause of adverse events and that the use of abbreviations is a barrier to effective communication.

Other 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 per cent of all errors
• The second most common abbreviations resulting in medication errors were "U" for units, "cc" for mL, "MSO4" or "MS" for morphine sulfate, and decimal errors
• 81 per cent of errors occurred during prescribing, while errors during transcribing and dispensing were much less frequent, representing only 14 and 2.9 per cent of errors respectively
• Abbreviation errors originated more often from medical staff in comparison to nursing, pharmacy, other healthcare providers, and non-healthcare providers
• The three most common types of abbreviation-related errors were prescribing, improper dose/quantity, and incorrectly prepared medication

For more information or to view the complete study, visit www.jcipatientsafety.org.