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The impact of
abbreviations on
patient safety
Introduction
• In 2004 The Joint Commission introduced
the “Do Not Use” list of abbreviations as
part of the requirements for meeting
International Patient Safety Goal 2
• which addresses the effectiveness of
communication among caregivers.
However, non-compliance
remains
23%
With a rising trend
Between 2004 - 2006
Medication errors have been
shown to account for up to
7,000 deaths per year in US
Institute of Medicine: To Err Is
Human: Building a Safer Health
System. Washington, D.C.: National
Academy Press, 2000.
• Communication failures are the most
common root cause of sentinel events.
• accounting for more than 60% of events
from 2002 through 2006.
The Joint Commission: Root Cause of
Sentinel Events.
(accessed Jun. 11, 2007).
• Frequently, communication lapses are the
result of using abbreviations when
conveying medication orders.
Aim
• The purpose of this study was to provide
further evidence about patient safety risks
that result from using abbreviations.
• MEDMARX® program is a medication error
reporting program.
• That allows subscribing facilities to report and
track medication errors in a standardized
format.
• MEDMARX uses the National Coordinating
Council for Medication Error Reporting and
Prevention (NCC MERP) Index for
Categorizing medication Errors to measure
error outcomes.
Sample
• From 2004 through 2006 a total of 643,151
medication errors were reported to the
MEDMARX program from 682 facilities.
• Of these errors, 29,974 (4.7%) were attributable
to abbreviation use.
• 11,821 of the abbreviation errors were excluded
due to lack of information.
• The final sample size consisted of 18,153
medication error reports.
Most common abbreviations
Error outcome
• The majority of errors were categories A, B, or C
(28%, 67.2%, and 3.8%, respectively).
• 0.3% of errors resulted in patient harm
Categories E through I.
About 54 patients
Node where error originated
Prescribing Transcribing
Dispensing Administration
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
81%
14%
3.00% 2%
Staff involved
Medical Nursing
Pharmacy Others
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
78.50%
15.10%
4.20% 2.20%
Most common abbreviations
associated with patient harm
Discussion
• Medication errors are often associated with
illegible handwriting of orders, which often
include abbreviations.
• Although the incidence of patient harm is
low, any incidence which can be avoided is a
target toward which everyone should strive.
• One may argue that errors originating at
prescribing node are less problematic.
• Because the pathway between prescribing
and patient receipt of the order is designed
to intercept errors.
• However, they do present unnecessary risk.
• Fundamentally, removal of the originating
causes of the error (that is, abbreviations) is
more sensible than relying on quality
control measures to intercept the error
before it reaches the patient.
• Education is often not enough; enforcement
is required to ensure that abbreviations are
not used.
• Holding health care professionals
accountable for infractions.
• Medical staff leadership must be engaged to
exert peer pressure and support for the
policy.
• Reward compliance.
The impact of abbreviations on patient safety jc
The impact of abbreviations on patient safety jc

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The impact of abbreviations on patient safety jc

  • 1. The impact of abbreviations on patient safety
  • 2.
  • 3. Introduction • In 2004 The Joint Commission introduced the “Do Not Use” list of abbreviations as part of the requirements for meeting International Patient Safety Goal 2 • which addresses the effectiveness of communication among caregivers.
  • 4.
  • 5. However, non-compliance remains 23% With a rising trend Between 2004 - 2006
  • 6. Medication errors have been shown to account for up to 7,000 deaths per year in US Institute of Medicine: To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press, 2000.
  • 7. • Communication failures are the most common root cause of sentinel events. • accounting for more than 60% of events from 2002 through 2006. The Joint Commission: Root Cause of Sentinel Events. (accessed Jun. 11, 2007).
  • 8. • Frequently, communication lapses are the result of using abbreviations when conveying medication orders.
  • 9. Aim • The purpose of this study was to provide further evidence about patient safety risks that result from using abbreviations.
  • 10. • MEDMARX® program is a medication error reporting program. • That allows subscribing facilities to report and track medication errors in a standardized format. • MEDMARX uses the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing medication Errors to measure error outcomes.
  • 11.
  • 12.
  • 13. Sample • From 2004 through 2006 a total of 643,151 medication errors were reported to the MEDMARX program from 682 facilities. • Of these errors, 29,974 (4.7%) were attributable to abbreviation use. • 11,821 of the abbreviation errors were excluded due to lack of information. • The final sample size consisted of 18,153 medication error reports.
  • 15.
  • 17. • The majority of errors were categories A, B, or C (28%, 67.2%, and 3.8%, respectively). • 0.3% of errors resulted in patient harm Categories E through I. About 54 patients
  • 18. Node where error originated
  • 23.
  • 24. Discussion • Medication errors are often associated with illegible handwriting of orders, which often include abbreviations. • Although the incidence of patient harm is low, any incidence which can be avoided is a target toward which everyone should strive.
  • 25. • One may argue that errors originating at prescribing node are less problematic. • Because the pathway between prescribing and patient receipt of the order is designed to intercept errors.
  • 26. • However, they do present unnecessary risk. • Fundamentally, removal of the originating causes of the error (that is, abbreviations) is more sensible than relying on quality control measures to intercept the error before it reaches the patient.
  • 27.
  • 28. • Education is often not enough; enforcement is required to ensure that abbreviations are not used. • Holding health care professionals accountable for infractions. • Medical staff leadership must be engaged to exert peer pressure and support for the policy. • Reward compliance.