USP Medication Safety Forum

Within the past decade medication errors have emerged as a significant patient safety concern and have been shown to account for up to 7,000 deaths per year. 1 One intervention aimed at reducing the incidence of medication errors is improving written or electronic communications, particularly in patient medical charts. In 2004 The Joint Commission introduced the “Do Not Use” list of abbreviations as part of the requirements for meeting National Patient Safety Goal 2, which addresses the effectiveness of communication among caregivers. Goal 2B requires health care organizations to maintain a standardized list of abbreviations, acronyms, and symbols that are not to be used. In addition to the “Do Not Use” list, the organization is required to develop additional restrictions pertaining to the use of abbreviations. In May 2005, the Joint Commission’s required “Do Not Use” list was reaffirmed (Table 1, page 578). Despite the list’s availability since 2004, noncompliance remains a frequent finding (23%) during Joint Commission surveys. Furthermore, annual Joint Commission survey results have shown a decreasing trend (from 75.2% to 64.2%) in compliance in hospitals from 2004 to 2006. Communication failures are the most common root cause of sentinel events, accounting for more than 60% of events from 2002 through 2006. Frequently, communication lapses are the result of using abbreviations when conveying medication orders. Staff responsible for reading, interpretation, and processing medication orders may not recognize or may misconstrue an abbreviation, resulting in the alteration of the intended meaning. An example commonly reported is the misinterpretation of the letter “U” intended to represent the word “units” being frequently interpreted as a 0 (that is, “10U” is misread as “100” units). If not caught, this error would likely result in the administration of an inappropriate dose, potentially harming patients. To our knowledge, however, the deleterious effect of using abbreviations has not been previously quantified. The purpose of this study was to provide further evidence about patient safety risks that result from using abbreviations. The United States Pharmacopeia (USP) MEDMARX program is a national medication error reporting program that allows subscribing facilities (hospitals and their related health systems) 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, in which Categories E through I indicate patient harm. The validity of this instrument was recently reaffirmed. The characteristics and impact of abbreviation use are summarized and analyzed in this article on the basis of error records submitted to MEDMARX between 2004 and 2006.