1. Medication safety program Prohibited Abbreviations

2. What is the extent of the problem?
DO WE HAVE A PROBLEM?
What is the extent of the problem?

3. How do errors happen? Patient receives wrong drug Latent Failures
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
Patient receives wrong drug
Latent Failures
Swiss Cheese Model
James Reason, 1991

4. 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.

5. 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.

6. 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

7. 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
Ramipril
Accounted 199/465 harmful incidents. (ISMP Canada; )
The 10 drugs accoun

8. Wake up call
2006 JCI surveys shows 22% of organizations non-compliant.
Death of infant - morphine

9. Responsibility Corporate P&T Committee Pharmaceutical Care
Nursing Services
Medical Services

10. Rx format Spend some time Addressograph
Allergy, height, weight & diagnosis
Generic name .
Legible handwriting.
Dose, route & frequencey
Signature & Badge #

11. Confusing?
2.0mg
.8mg
Nitro drip
Diagnosis: CA
Diagnosis USA

12. What is ?
II tablets 2d PRN
MWF
Dimix/ Diamox
CBZ
HCTZ

13. What is the extent of the problem?
HELP!!!
What is the extent of the problem?

14. 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

15. 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:

16. 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

17. Short List of Error-Prone Notations Continued
Notation Reason Instead Use
QOD Mistaken for QID, QD “every other day”
Trailing zero Decimal point missed “X mg”
(X.0 mg)
Naked decimal Decimal point missed “0.X mg”
point
(.X mg)

18. Short List of Error-Prone Notations Continued
Notation Reason Instead Use
MS Can mean morphine “morphine sulfate”
sulfate or magnesium
sulfate
MSO4 and Can be confused with “morphine sulfate”
MgSO4 each other or “magnesium sulfate”
cc Mistaken for U “mL”

19. Short List of Error-Prone Notations Continued
Notation Reason Instead Use
Drug name Mistaken for other drugs Complete
abbreviations or notations drug name
(especially those
ending in “l”)
> or < Mistaken as opposite “greater than”
of intended or “less than”
μ Mistaken for mg “mcg”

20. Short List of Error-Prone Notations Continued
@ Mistaken for “at”
& Mistaken for “and”
/ Mistaken for “per” rather than a slash mark
Mistaken for 4 “and”
Notation Reason Instead Use

21. Short List of Error-Prone Notations Continued
Notation Reason Instead Use
AD, AS, AU Mistaken for OD, OS, OU “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 “discharge” or “discontinued” when “discontinued”
followed by list of
medications

22. 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.

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

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

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

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

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

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

29. 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

30. Recommendations for Healthcare Professionals
Avoid ambiguous abbreviations in written orders, computer-generated 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.

31. 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.

32. 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.

33. Other Resources www.ismp.org/tools/abbreviations
For more information and tools to help promote safe practices, visit: or

34. 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?

35. Thank You