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Broad approach to eliminate error-prone medication abbreviations

Case Study

posted by Alastair McLean on 16 August 2012

The Health Quality & Safety Commission’s Medication Safety Programme is using a multi-pronged approach to eliminate the use of error-prone medication abbreviations. Unclear abbreviations are a major cause of medication errors.

The Commission recently polled its newsletter readers about what they thought the dose was in the prescription at left.

Nearly half the 82 participants were unable to read the dose correctly, as shown in the accompanying graph. Many commented on the unusual dose, its poor legibility and the need to contact the doctor before doing anything.

The correct answer was 4 micrograms.

Commission Medication Safety Specialist, Nirasha Parsotam, says the results weren’t a surprise and were in line with similar polls taken in education and training settings.

‘These days abbreviations are everywhere, but the consequences of information being misinterpreted can be far greater in health care, and international data clearly shows the use of abbreviations is associated with errors. Even if the mistake is caught, it has still been made.

‘While abbreviations, acronyms and symbols are perceived to save time, they’re not interpreted uniformly by health practitioners who have to think about it and perhaps check it, so they don’t save time in the long run. People also tend to put abbreviations into a familiar context and may not even realise their interpretation is wrong.’

She says many abbreviations can have more than one meaning. ‘EPO means evening primrose oil to vitamin manufacturers, but to renal teams it means the kidney hormone, erythropoietin.’

While cursive hand writing can be mistaken easily for another abbreviation, typed abbreviations are also prone to misinterpretation in poor lighting or if unclear typefaces are used. Letters can appear to merge and OD (daily) can be read as BD (twice per day). ‘We know errors are still happening with computer generated labels and medicine storage labels.’

Ms Parsotam’s audit of the first version of the national medication chart found 38 percent of the medicines audited contained an error-prone abbreviation.

In April, the Commission distributed a poster and quick reference card listing abbreviations, symbols and dose designations that have been reported internationally as being frequently misinterpreted and involved in harmful medication errors. These are abbreviations that should never be used when communicating medicine-related information verbally, handwritten, pre-printed or electronically. The poster can be accessed on the HQSC website.

The regulatory body MedSafe has also engaged in the process and will be checking for the use of error-prone abbreviations when it reviews labelling of new products to the markets.

‘Everyone involved in the medicine process - from manufacturers to regulators to health professionals - need to be part of this international movement to eliminate error-prone medication abbreviations.

‘As well as educating people about the risks, it means reviewing all policies, procedures, guidelines, training materials and text books, and all communication forms, including internal communications, telephone and verbal prescriptions.’