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Use of medical abbreviations in medicine is not new. Since the development of mainstream medicine nearly 200 years ago, abbreviations have been used. While initially, the abbreviations were limited to the writing of prescriptions, today, abbreviations have become very common in all aspects of medical documentation. Medical abbreviations are used in all medical and surgical departments, during surgery, the emergency room, and at discharge. One area where medical abbreviations are used most often and are a cause for concern is when writing drug orders. Until recently, the use of abbreviations has never been regulated, and there is no universal rule as to which abbreviations can be used and which ones cannot. In fact, over the past 3 decades, some healthcare workers have been making up abbreviations. The long-standing practice of writing medical abbreviation has become so entrenched in healthcare that even the most junior medical and nursing school graduates are very accustomed to writing them. In fact, many healthcare institutions have specialized lists of abbreviations that can be used. Now, with a more formalized practice of medicine, there is a concern that rampant use of medical abbreviations may pose a danger to the patient. While there are anecdotal examples of medical abbreviations that have caused harm to a few patients, good clinical evidence to support the belief that medical abbreviation use is dangerous or is causing problems in the delivery of standard of care is lacking. In any case, the potential for harm to the patient from improper communication as a result of medical abbreviations cannot be understated. This activity reviews the inappropriate use of medical abbreviations and discusses the role of the interprofessional team in avoiding acting on orders that are unclear due to the use of an abbreviation.

Objectives:Describe the errors reported by the ISMP and Joint Commission related to inappropriate medical abbreviations.Outline methods to avoid acting on inappropriate and unclear medical abbreviations.Identify examples of potential harm that can result from inappropriate medical abbreviations.Summarize the inappropriate use of medical abbreviations and highlight the role of the interprofessional team in avoiding acting on orders that are unclear due to the use of an abbreviation.Access free multiple choice questions on this topic.

Medical Abbreviations Pdf Download

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The use of medical abbreviations in medicine is not new. Since the development of mainstream medicine nearly 200 years ago, abbreviations have been used. While initially, the abbreviations were limited to the writing of prescriptions, today, abbreviations have become very common in all aspects of medical documentation. Medical abbreviations are used in all medical and surgical departments, during surgery, in the emergency room, and at discharge. One area where medical abbreviations are used most often and are a cause for concern is when writing drug orders. Until recently, the use of abbreviations has never been regulated, and there is no universal rule as to which abbreviations can be used and which ones cannot. In fact, over the past three decades, some healthcare workers have been making up abbreviations. The long-standing practice of writing medical abbreviations has become so entrenched in healthcare that even the most junior medical and nursing school graduates are accustomed to writing them. In fact, many healthcare institutions have specialized lists of abbreviations that can be used. The use of medical abbreviations is not only an American phenomenon but a global problem.

For the past three decades, healthcare leaders have been encouraging less use or even eliminating medical abbreviations in medicine. The US Institute of Safe Medication Practices (ISMP) has regularly received a continual stream of reported errors, some of which have resulted in adverse events due to misinterpretation of some dangerous medical abbreviations. The Joint Commission has regularly issued updates and regulations on the safe use of medical abbreviations and, in fact, has also published a short list of dangerous medical abbreviations and dose expressions that should never be used. However, despite many key organizations condemning the use of medical abbreviations, they continue to be used at an alarming rate. Medical abbreviations are almost routine in any medical chart or drug prescription. This can often place junior healthcare staff who are supposed to decipher the drug orders at significant risk because often the healthcare provider who writes the medical abbreviations may not be around, and the junior staff or nurse may use their limited knowledge to determine what the abbreviations exactly mean. The other alternative is to refuse to carry out any order where the abbreviations do not make sense, but this refusal can also jeopardize a patient's healthcare.

Now, with a more formalized practice of medicine, there is a concern that the rampant use of medical abbreviations may pose a danger to the patient. While there are anecdotal examples of medical abbreviations that have caused harm to a few patients, good clinical evidence to support the belief that medical abbreviation use is dangerous or is causing problems in the delivery of standard of care is lacking. In any case, the potential for harm to the patient from improper communication due to medical abbreviations cannot be understated.[1][2]

The limited publications show physicians are responsible for writing the vast majority of medical abbreviations. In private practice, it is usually the physician who writes medical abbreviations, but in large teaching hospitals, the medical and surgical residents write the most medical abbreviations since they are the ones tasked with the writing of orders. However, other healthcare professionals who also regularly write medical abbreviations include dietitians, nurses, occupational and physical therapists, and social workers, albeit not in great numbers.

One of the biggest problems leading to medical errors is the failure to communicate, and this is made worse with the use of medical abbreviations, which can have multiple meanings. Further communication lapses are often the result of using medical abbreviations, especially when writing medication orders for junior staff. The staff responsible for reading, interpreting, and processing the medication order may misconstrue the abbreviation or may not even recognize it, leading to an erroneous meaning. For example, one very commonly reported misinterpretation of dosing is the use of a decimal point after a dose. For example. 5.0 is often mistaken for 50; if the dot is not seen, this can result in ten times the dose.[3]

The National Medication Error Reporting program is run by the US pharmacopeia MedMarx. This program permits subscribing healthcare institutions to report and track medication errors in a standard format. From 2004 through 2006, there were 643,151 medication errors reported to MedMarx from 682 facilities, of which 4.7% (29,974) were attributed to the use of medical abbreviations.

From these data, the most common medical abbreviation error was the use of QD (once daily), accounting for 43.1% of all errors, followed by U for units, cc for ml, and other decimal errors. The most common drug abbreviation name that led to an error was the use of MS or MS04 for morphine sulfate. At least 81% of the errors were noted to occur at the time of ordering the medication, while errors at the transcribing and dispensing area occurred at a lower frequency. The administration, procurement, and monitoring processes were associated with less than 2% of the total errors. Overall, it appears that the three most common errors due to medical abbreviations were errors in prescribing, improper dose/quantity, and incorrect preparation of the medication. However, the consequences of using these medical abbreviations were not completely reported.

But irrespective of whether medical abbreviations are causing harm, no one argues that they can result in miscommunication because the other healthcare staff who are responsible for reading and processing orders may not be familiar with or even recognize these abbreviations, which can result in gross errors in dispensing or administration of a medication or a test. Several studies have looked at critical incidents and adverse events in hospitals. In many cases, it was observed that some medical abbreviations were dangerous, resulting in inappropriate dose administration or frequency.[4]

Within the past two decades, there have been many reports about medication errors, and patient safety remains a concern. It is estimated that medication errors alone account for anywhere from 7000 to 10,000 deaths annually in the United States. While medication errors have many causes, one of the ways to reduce these errors is by improving written communication, whether electronic or written. In 2004, the Joint Commission developed the "Do Not Use" list of medical abbreviations as part of the requirements for meeting the National Patient Safety Goal, which primarily addresses the effectiveness of communication between healthcare workers. The Joint Commission has also recommended that all healthcare institutions create a standard list of acronyms, abbreviations, and symbols that should not be used. However, despite the development of "Do Not Use" lists, compliance is not 100%.

Further, the Joint Commission has banned the use of medical abbreviations in documents that pertain to patient rights, informed consent forms, discharge instructions, and all other documents that a patient and the family may receive from the healthcare institution.

The Joint Commission has also recommended having a uniform and standardized list of symbols, codes, and abbreviations that can enhance communication and understanding among healthcare workers, leading to improved patient safety. Many healthcare workers have consistently reported that they have a great deal of difficulty interpreting medical abbreviations, even in their own hospitals. e24fc04721