Medication errors related to potentially dangerous abbreviations

One of the major causes of medication errors is the ongoing use of potentially dangerous abbreviations and dose expressions. Underlying factors contributing to many of these errors are illegible or confusing handwriting by clinicians and the failure of health care providers to communicate clearly with one another. Because medication safety and the identification, prevention and timely reporting of medication errors are of primary importance to the Joint Commission, this issue of Sentinel Event Alert specifically addresses medication errors related to the use of dangerous abbreviations and dose expressions used in prescribing medications.

Despite repeated warnings for more than 25 years by the Institute for Safe Medication Practices (ISMP)--and other organizations--about the dangers associated with using certain abbreviations when communicating medication information, the practice of using these dangerous abbreviations continues, increasing the potential for patient harm. "Symbols and abbreviations are frequently used to save time and effort when writing prescriptions and documenting in patient charts," says Darryl S. Rich, Pharm.D., M.B.A., FASHP, associate director, Surveyor Development and Management, JCAHO. "However, some symbols and abbreviations have the potential for misinterpretation or confusion."

Examples of especially problematic abbreviations include "U" for "units" and "µg" for "micrograms." When "U" is handwritten, it can often look like a zero. There are numerous case reports where the root cause of sentinel events related to insulin dosage has been the interpretation of a "U" as a zero. Using the abbreviation "µg" instead of "mcg" has also been the source of errors because when handwritten, the symbol "µ" can look like an "m". The use of trailing zeros (e.g., 2.0 vs. 2) or use of a leading decimal point without a leading zero (e.g. .2 instead of 0.2) are other dangerous order writing practices. The decimal point is sometimes not seen when orders are handwritten using trailing zeros or no leading zeros. Misinterpretation of such orders could lead to a 10-fold dosing error. "To minimize the potential for error and to maximize patient safety, prescribers need to avoid such specifically dangerous abbreviations and phrases," Dr. Rich says.

ISMP issues wake-up call

Following the tragic death of an infant due to the misinterpretation of a prescription for morphine, ISMP recently issued a wake-up call to health care institutions reminding them of the dangers of utilizing certain dangerous abbreviations and dose expressions. (1)  "ISMP and others have advocated abandoning the use of these abbreviations and expressions for almost three decades," says Michael Cohen, D.Sc., M.S., FASHP, president, ISMP. "ISMP has also stressed that it is equally important to avoid these dangerous abbreviations and dose expressions in other communications such as computer-generated labels, Medication Administration Records (MARs), labels for drug storage bins/shelves, preprinted orders and protocols, and pharmacy and prescriber order entry screens." A table of dangerous abbreviations and dose expressions most often associated with misinterpretation and patient harm (as reported to the USP-ISMP Medication Errors Reporting Program) may be obtained from the ISMP website at www.ismp.org.

In addition, NCC MERP (National Coordinating Council for Medication Error Reporting and Prevention) in 1996 issued "Recommendations to Correct Error-Prone Aspects of Prescription Writing" (2) and U.S. Pharmacopeia in 1997 issued "Recommendations for Prescription Writing," (3)  which discuss ways organizations can avoid medication errors and minimize risks to patients.

Risk reduction strategies

Though new technologies such as computerized order entry systems are being introduced into health care, it is estimated that currently less than 5 percent of U.S. physicians utilize these systems and write their prescriptions electronically. The related costs and training issues are most often cited as reasons why organizations do not adopt these new technologies. However, by moving toward electronic prescribing systems, organizations can most certainly minimize medication errors, including those related to poor handwriting, thus drastically reducing the risks to patients and the costs associated with drug-related morbidity and mortality. (4)  Realizing that most health care organizations will not be able to implement this new, costly technology in the near term, JCAHO has identified some cost efficient and effective risk reduction strategies that any health care organization can adopt:

• Develop a list of unacceptable abbreviations and symbols that is shared with all prescribers.
• Develop a policy to ensure that medical staff refer to the list, and take steps to ensure compliance.
• Establish a policy that if an unacceptable abbreviation is used, the prescription order is verified with the prescriber prior to its being filled.

Recommendations

Examples of correct and incorrect use of decimal points and zeros: Correct Incorrect 2. or 2 2.0 0.2 .2

The Joint Commission requires that medication orders have "the degree of accuracy, completeness, and discrimination necessary for their intended use" (JCAHO standard IM.3 in all manuals). Standard IM.3 also requires the use of standardized abbreviations, acronyms and symbols. Use of confusing and dangerous abbreviations is not consistent with the intent of this standard. Furthermore, hospitals are to assess/review orders in the medical record for "presence, timeliness, legibility, and authentication," and see that "action is taken to improve the quality and timeliness of documentation that impacts patient care" (IM.7.10 in the Comprehensive Accreditation Manual for Hospitals). This should be done as part of the quarterly medical record review that hospitals undertake for record completeness and authentication. As part of the review, standard IM.7.10 clearly requires that legibility be addressed as well as completeness and authentication.

In addition, MS.8.2.3 (Comprehensive Accreditation Manual for Hospitals) requires that data regarding "accurate, timely and legible completion of patient's medical records" be specifically addressed in the privileging and credentialing program, and that this data must not only be aggregate data, but how specific physicians do compared to the norm. Failure to do so can result in multiple Type I recommendations, even if not part of a Medication Use Evaluation or Performance Improvement program. Multiple Joint Commission standards require legibility of physician orders and that hospitals take appropriate action to improve the legibility of physician orders. Finally, standard TX.3.5.2 (Comprehensive Accreditation Manual for Hospitals) requires pharmacists to review all medication orders and to contact the prescriber, if questions arise. In order to achieve compliance with these standards, strategies to reduce the inappropriate use of dangerous abbreviations need to be taken, such as those identified in this alert's risk reduction strategies.

References

1. ISMP Medication Safety Alert!, May 2, 2001, www.ismp.org.
2. "Recommendations to Correct Error-Prone Aspects of Prescription Writing," NCC MERP Council Recommendation, adopted Sept. 4, 1996, at www.nccmerp.org (under Council Recommendations).
3. "Recommendations for Prescription Writing, " USP Quality Review, No. 57, Jan. 1997, www.usp.org (search keyword "abbreviations").
4. Electronic Prescribing Can Reduce Medication Errors, white paper from the Institute for Safe Medication Practices, www.ismp.org.

Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future.

During the on-site survey of accredited organizations, Joint Commission surveyors assess the organization's familiarity with and use of Sentinel Event Alert information. Accredited organizations are expected to:

• Review and consider relevant information, if appropriate to the organization's services, from each Sentinel Event Alert.
• Consider information in an alert when designing or redesigning relevant processes.
• Evaluate systems in light of information in an alert. 
• Consider standard-specific concerns.
• Implement relevant suggestions or reasonable alternatives or provide a reasonable explanation for not implementing relevant changes. Failure to do so will result in a type I recommendation.

Setting the Standard for Quality in Health Care
The Joint Commission
Sentinel Event Hotline (630) 792-3700

Please route this issue to appropriate staff within your organization. Sentinel Event Alert may only be reproduced in its entirety and credited to The Joint Commission.