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CKHS Strives to Reduce the Use of Unsafe Medication Abbreviations

As part of its mission to provide the best quality care, Crozer-Keystone Health System has made efforts to reduce the use of unsafe abbreviations when prescribing medication to patients.

According to The Joint Commission, “medication errors continue to be one of the most frequent causes of preventable harm in healthcare."

Many of these errors occur through the use of medication abbreviations, explains Mary Moser-Grimes, director of Quality at Delaware County Memorial Hospital. “Many practitioners were taught to use abbreviations in medical and nursing schools. We want to try to instill in them that they are potentially harming a patient when they use an abbreviation,” Moser-Grimes says. “But through continuous efforts, our staff has been compliant and has strived to provide patient safety."

Other reasons why abbreviations may lead to error:

  • Clinicians may write an illegible prescription that is misread
  • Healthcare providers may not communicate effectively
  • Practitioners may mistake an abbreviation for another medication or dosage. 

In 2001, The Joint Commission issued a Sentinel Event Alert to address the medication errors that were directly related to the use of abbreviations. A Sentinel Event Alert provides information about a healthcare problem and how to prevent the problem from occurring again.

To help continue to reduce unsafe abbreviation errors in all health systems, The Joint Commission issued an official “Do Not Use” list in 2004. This list was created by The Joint Commission as a requirement for the National Patient Safety Goals. The National Patient Safety Goals provide guidance for organizations to improve patient safety issues that all healthcare systems are struggling to manage effectively.

The “Do Not Use” list includes widely used abbreviations that may cause the most harm to patients. For example, a doctor may write a prescription for a patient and write “10U,” which means “10 Units.” Due to poor communication or illegible handwriting, a nurse may misread the order, give 100 units and administer an incorrect dosage. Now, because The Joint Commission has issued a “Do Not Use” list, doctors and medication administrators must write out full words instead of abbreviations.

The Official Do Not Use List:

  • Do Not Use “U,” Write “Unit”
  • Do Not Use “IU,” Write “International Unit”
  • Do Not Use “Q.D.,” Write “Daily”
  • Do not Use “Q.O.D.,” Write “Every Other Day”
  • Do Not Use “X.0 mg” or “.X mg,” Use “X mg” or “0.X mg”
  • Do Not Use “MS,” Write “Morphine Sulfate”
  • Do Not Use “MSO4” or “MgSO4,” Write “Morphine Sulfate” or “Magnesium Sulfate” 

CKHS has strived to develop practices that reduce the use of unsafe abbreviations and provide the safest care to its patients. Joan Marino, director of Accreditation and Regulatory Services at Crozer-Chester Medical Center, Springfield Hospital and Community Hospital, says the biggest challenge with reducing abbreviations is changing practitioners’ behaviors and habits.

“Our overall goal at CKHS is to provide the safest care to our patients. We work closely with our physicians and other clinicians to help them understand why unsafe abbreviations should not be used,” Marino says.

Crozer-Keystone has developed practices that have helped reduce the use of abbreviations and has increased patient safety and quality in the hospitals. Each CKHS hospital has a “Do Not Use” abbreviation list as well as a list of approved abbreviations.

Some actions CKHS has taken to reduce the use of abbreviations:

  • Place unapproved abbreviations on the system order sheets and regularly point them out to staff
  • Audit charts to determine how often abbreviations are being used
  • Distribute badge cards containing lists of the unapproved abbreviations
  • Display posters throughout the hospitals that contain information about the importance of reducing abbreviations
  • Educate doctors and nurses about the dangers of using abbreviations 
  • Redid Insulin Kardex so the word “unit” is preprinted so that no one has to use the “u” abbreviation.

Among the health system’s future plans and actions to reduce the use of abbreviations:

  • Maintain physician report cards that include the use of unsafe abbreviations
  • Evaluate and monitor healthcare provider practices 
  • Have the Pharmacy send copies of medication order sheets that use incorrect abbreviations or that are illegible to be reviewed
  • Educate new employees about the importance of the reduction of abbreviations
  • Enter staff into a disciplinary process for repeated offenses.

Since first working to reduce the use of abbreviations in 2003, CKHS has made improvements over the years. Barbara Shaner, director of QM&I at Taylor Hospital, has noticed improvement with reducing abbreviation use.

“Over the last few years, we have made inroads. Sharing of events related to the abbreviation of “units” and insulin errors have made physicians pause and make a conscientious effort to reduce unsafe abbreviations. We ask staff to try not to abbreviate at all,” Shaner says. “There has also been improvement because we now have electronic documentation for nursing. I try to find out why the individual has used a certain abbreviation and what the barriers are for that person not to do so.”

Patients can also make sure they are receiving the right medication. According to The Joint Commission Speak Up™ Program, patients should ask their doctors questions if they have any concerns with the medication prescribed to them. If patients start to feel side effects from the medication, they should let their doctor know right away so something can be done to help them.

Physicians or anyone else who has questions about the use of medication abbreviations can contact Moser-Grimes, (610) 284-8768 (12-8768); Marino, (610) 447-2787 (15-2787); or Shaner, (610) 595-6042 (19-6042).

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