Medication safety Medication safety programprogram

Prohibited AbbreviationsProhibited Abbreviations

DO WE HAVE A PROBLEM?DO WE HAVE A PROBLEM?

What is the extent of the What is the extent of the problem?problem?

How do errors happen?How do errors happen?

Patient receives wrong drug

Barriers & Safeguards against

Errors

Poorly Designed Order Forms

Inadequate Training and Skills Mix

Multiple Demands on Attention

Poorly Designed Storage Facility

Poor Lighting

Poorly Designed Drug Packaging

Latent Failure

sSwiss Cheese ModelJames Reason, 1991

StudiesStudies

Although abbreviations in health care may Although abbreviations in health care may be efficient, their use comes at the expense be efficient, their use comes at the expense of patient safety.of patient safety.

according to a study published in the according to a study published in the September 2007 issue of September 2007 issue of The Joint The Joint Commission Journal on Quality and Patient Commission Journal on Quality and Patient SafetySafety. .

The ProblemThe Problem

using Abbreviations are one of the most common using Abbreviations are one of the most common and preventable causes of medication errors.and preventable causes of medication errors.

Drug names, dosage units, and directions for use Drug names, dosage units, and directions for use should be written clearly to minimize confusion.should be written clearly to minimize confusion.

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Consequences of Consequences of Using Error-Prone AbbreviationsUsing Error-Prone Abbreviations

Misinterpretation may lead to mistakes that Misinterpretation may lead to mistakes that result in patient harm result in patient harm

Delay start of therapy due to time spent for Delay start of therapy due to time spent for clarificationclarification

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Top 10 Reported as causing harmTop 10 Reported as causing harm

Generic NameGeneric Name # of # of ReportsReports

InsulinInsulin 5454

MorphineMorphine 4343

HydromorphoneHydromorphone 3232

Heparin (unfractionated)Heparin (unfractionated) 1919

FentanylFentanyl 1111

WarfarinWarfarin 1010

FurosemideFurosemide 99

DalteparinDalteparin 77

MetoprololMetoprolol 77

RamiprilRamipril 77

Accounted 199/465 harmful incidents. (ISMP Canada; 2001-2005)

Wake up callWake up call

2006 JCI surveys shows 22% of 2006 JCI surveys shows 22% of organizations non-compliant.organizations non-compliant.

Death of infant - morphineDeath of infant - morphine

ResponsibilityResponsibility

Corporate P&T CommitteeCorporate P&T Committee Pharmaceutical CarePharmaceutical Care Nursing ServicesNursing Services Medical ServicesMedical Services

Rx formatRx format

Spend some timeSpend some timeAddressographAddressographAllergy, height, weight & diagnosis Allergy, height, weight & diagnosis Generic name .Generic name .Legible handwriting.Legible handwriting.Dose, route & frequenceyDose, route & frequenceySignature & Badge #Signature & Badge #

Confusing?Confusing?

2.0mg2.0mg .8mg.8mg Nitro dripNitro drip Diagnosis: CADiagnosis: CA Diagnosis USADiagnosis USA

What is ?What is ?

1 + 1 + 11 + 1 + 1 II tablets 2d PRNII tablets 2d PRN MWFMWF Dimix/ DiamoxDimix/ Diamox CBZCBZ HCTZHCTZ

HELP!!!HELP!!!

What is the extent of the What is the extent of the problem?problem?

TipsTips Identify and promote “physician Identify and promote “physician

champions”champions” The key is to prevent the abbreviations from The key is to prevent the abbreviations from

being writtenbeing written catch physicians before they depart from catch physicians before they depart from

the patient care area. the patient care area. Nurses may assistNurses may assist check abbreviations PRIORcheck abbreviations PRIOR

Implement “Do Not Use” ListImplement “Do Not Use” List

The Institute for Safe Medication Practices The Institute for Safe Medication Practices (ISMP) and the Food and Drug Administration (ISMP) and the Food and Drug Administration recommend that ISMP’s list of error-prone recommend that ISMP’s list of error-prone abbreviations be considered whenever medical abbreviations be considered whenever medical information is communicated.information is communicated.

Complete list is located at:Complete list is located at:

www.ismp.org/Tools/errorproneabbreviations.pdf

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Short List of Error-Prone NotationsShort List of Error-Prone Notations**

The following notations should NEVER be used.The following notations should NEVER be used.

NotationNotation ReasonReason Instead UseInstead Use

U U Mistaken for 0, 4, ccMistaken for 0, 4, cc “unit”“unit”

IU IU Mistaken for IV or 10Mistaken for IV or 10 “unit”“unit”

QDQD Mistaken for QIDMistaken for QID “daily”“daily”

*Comprises “do not use” list required for JCAHO accreditation*Comprises “do not use” list required for JCAHO accreditation

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Short List of Error-Prone Notations Short List of Error-Prone Notations ContinuedContinued

NotationNotation ReasonReason Instead UseInstead UseQODQOD Mistaken for QID, QDMistaken for QID, QD “every “every

other day”other day”

Trailing zero Trailing zero Decimal point missedDecimal point missed “X mg”“X mg”(X.0 mg)(X.0 mg)

Naked decimal Naked decimal Decimal point missed Decimal point missed “0.X mg” “0.X mg” pointpoint(.X mg)(.X mg)

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Short List of Error-Prone Notations Short List of Error-Prone Notations ContinuedContinued

NotationNotation ReasonReason Instead UseInstead UseMSMS Can mean morphineCan mean morphine “morphine sulfate”“morphine sulfate”

sulfate or magnesiumsulfate or magnesiumsulfatesulfate

MSOMSO44 and and Can be confused withCan be confused with “morphine sulfate”“morphine sulfate”

MgSOMgSO44 each othereach other or “magnesium or “magnesium

sulfate” sulfate”

cccc Mistaken for UMistaken for U “mL”“mL”

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Short List of Error-Prone Notations Short List of Error-Prone Notations ContinuedContinued

NotationNotation ReasonReason Instead UseInstead UseDrug name Drug name Mistaken for other drugs Mistaken for other drugs Complete Complete abbreviationsabbreviations or notationsor notations drug namedrug name(especially those (especially those ending in “l”)ending in “l”)

> or <> or < Mistaken as opposite Mistaken as opposite “greater than”“greater than”of intendedof intended or “less than” or “less than”

μμ Mistaken for mgMistaken for mg “mcg”“mcg”

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Short List of Error-Prone Notations Short List of Error-Prone Notations ContinuedContinued

NotationNotation ReasonReason Instead Instead UseUse

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@@ Mistaken for 2Mistaken for 2 “at” “at”

&& Mistaken for 2 “and”Mistaken for 2 “and”

// Mistaken for 1Mistaken for 1 “per” “per” rather rather than than a slash a slash mark mark

++ Mistaken for 4 Mistaken for 4 “and”“and”

Short List of Error-Prone Notations Short List of Error-Prone Notations ContinuedContinued

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NotationNotation ReasonReason Instead UseInstead UseAD, AS, AUAD, AS, AU Mistaken for OD, OS, OUMistaken for OD, OS, OU “right ear,” “right ear,”

“left ear,” “left ear,” or “each ear”or “each ear”

OD, OS, OUOD, OS, OU Mistaken for AD, AS, AUMistaken for AD, AS, AU “right eye,” “right eye,” “left eye,” “left eye,” or “each eye”or “each eye”

D/C, dc, d/cD/C, dc, d/c Misinterpreted as Misinterpreted as “discharge” or “discharge” or “discontinued” when “discontinued” when “discontinued”“discontinued”followed by list of followed by list of medicationsmedications

Other Good PracticesOther Good Practices

Drug name abbreviations can easily be Drug name abbreviations can easily be confused. Always write out complete drug confused. Always write out complete drug name.name.

Apothecary units are unfamiliar to many Apothecary units are unfamiliar to many practitioners. Always use metric units.practitioners. Always use metric units.

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ExamplesExamples

Intended dose of 4 units in patient history Intended dose of 4 units in patient history interpreted as 44 units. “U” should be written interpreted as 44 units. “U” should be written out as “unit.”out as “unit.”

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ExamplesExamples

Intended dose of “.4 mg” interpreted as 4 Intended dose of “.4 mg” interpreted as 4 mg from medication order. Should be mg from medication order. Should be written as “0.4 mg.”written as “0.4 mg.”

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ExamplesExamples

““Potassium chloride QD” in medication order Potassium chloride QD” in medication order interpreted as QID. Should be written as interpreted as QID. Should be written as “daily.”“daily.”

25

ExamplesExamples

Intended recommendation of “less than 10” Intended recommendation of “less than 10” was interpreted as 4. “<” should be written out was interpreted as 4. “<” should be written out as “less than.”as “less than.”

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ExamplesExamples

““QD” in advertisement should be written out as QD” in advertisement should be written out as “daily.”“daily.”

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ExamplesExamples

““U” in prominent professional journal article U” in prominent professional journal article should be written out as “unit.”should be written out as “unit.”

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Do Not Use Error-Prone Do Not Use Error-Prone Abbreviations Even in PrintAbbreviations Even in Print

May still be confused May still be confused

Perpetuates the impression that they are Perpetuates the impression that they are acceptableacceptable

May be copied into written ordersMay be copied into written orders

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Recommendations for Recommendations for Healthcare ProfessionalsHealthcare Professionals

Avoid ambiguous abbreviations in written orders, computer-Avoid ambiguous abbreviations in written orders, computer-generated labels, medication administration records, storage generated labels, medication administration records, storage bins/shelf labels, and preprinted protocols.bins/shelf labels, and preprinted protocols.

Work with computer software vendors to make changes in Work with computer software vendors to make changes in electronic order entry programs.electronic order entry programs.

Provide examples when educating staff on how using error-prone Provide examples when educating staff on how using error-prone abbreviations have led to serious patient harm.abbreviations have led to serious patient harm.

Provide staff with ISMP’s list of error-prone abbreviations.Provide staff with ISMP’s list of error-prone abbreviations.

Introduce healthcare students to the list of error-prone Introduce healthcare students to the list of error-prone abbreviationsabbreviations..

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Recommendations for Recommendations for Pharmaceutical IndustryPharmaceutical Industry

Review existing drug labeling and packaging as well as new Review existing drug labeling and packaging as well as new drug applications for use of error-prone abbreviations.drug applications for use of error-prone abbreviations.

Eradicate use of ambiguous abbreviations in product Eradicate use of ambiguous abbreviations in product advertising (both in graphics and text).advertising (both in graphics and text).

Check for error-prone abbreviations in all communications Check for error-prone abbreviations in all communications vehicles, including slides, promotional kits, and sales staff vehicles, including slides, promotional kits, and sales staff training materials.training materials.

Include ISMP’s list in corporate editorial style guidelines.Include ISMP’s list in corporate editorial style guidelines.

Incorporate list into software and medical device design.Incorporate list into software and medical device design.

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Recommendations for Medical Recommendations for Medical Communications/Publishing ProfessionalsCommunications/Publishing Professionals

Make “do not use list” of notations as part of Make “do not use list” of notations as part of publishing style manuals and internal style guides for publishing style manuals and internal style guides for clinical writing.clinical writing.

Add the list of error-prone abbreviations to Add the list of error-prone abbreviations to instructions for journal authors.instructions for journal authors.

Review all internal and external communications Review all internal and external communications products for ambiguous abbreviations.products for ambiguous abbreviations.

Eliminate error-prone abbreviations in company-wide Eliminate error-prone abbreviations in company-wide educational and training sessions.educational and training sessions.

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Other ResourcesOther Resources

For more information and tools to help For more information and tools to help promote safe practices, visit:promote safe practices, visit:

www.ismp.org/tools/abbreviationsoror

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 YouThank You