Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Abbreviations: A Shortcut to Medication Errors T hroughout healthcare, “shortcuts” such as abbre- viations and symbols are often used to save time when communicating medication orders, especially in breviation “U” instead of writing the word “unit” (see Figure 1). The physician then misread the “U” as a “4” and wrote for “Humalog 44 U/24 U/64 U.” The patient handwritten communication. However, some of these received a single overdose of insulin but was not shortcuts can be very time-consuming for the person harmed. Further overdoses were averted because the on the receiving end and can be dangerous to the nurse said to the patient “Here’s your insulin, 44 patient. Abbreviations and nonstandard dose desig- units.” The patient responded “44 units? I take 4 nations are frequently misinterpreted, and they often units!”1 lead to errors resulting in patient harm. PA-PSRS has received over 200 reports describing situations in which the use of abbreviations has led to medication errors. Some of the common error-prone abbreviations involved in errors in PA-PSRS include: Figure 1. “4U” Mistaken for “44.” Image provided courtesy of • “U” for unit ISMP. • “QD” for daily • “QID” for four times daily Some abbreviations used to indicate the frequency of • “QOD” for every other day drug administration (e.g., QD and QOD) can be prob- • “<” for less than lematic as well. In one report received through the • “>” for greater than MERP, an order (see Figure 2) for Flomax • “cc” for cubic centimeter (tamsulosin) 0.4 mg QD was misinterpreted as Flo- • “D/C” for discontinue max 0.4 mg QID. Fortunately, the error was caught prior to the patient’s being harmed.2 • “AU” for both ears • “OU” for both eyes • Drug name abbreviations − MSO4 for morphine sulfate − MgSO4 for magnesium sulfate Figure 2. “QD” Mistaken for “QID.” Image provided courtesy of − HCTZ for hydrochlorothiazide ISMP. One of the error-prone abbreviations most commonly Several instances of this abbreviation causing errors reported to PA-PSRS is the abbreviation “U” used to have also been reported to PA-PSRS. In one case, indicate “units.” This abbreviation contributes to er- an order for Zithromax (azithromycin) 500 mg written rors when it is misread as a zero (0) or as the number as QD was misinterpreted as QID. Luckily, there was 4. These errors often result in potential 10-fold or no harm despite the patient’s receiving the medication greater overdoses. In one example, an older male four times daily. In another report, an order was writ- patient was ordered 5 units of Humalog (insulin lispro ten for Digoxin 0.125 mg po QOD (every other day), recombinant) but received 50 units of Humalog on two occasions. The order on the medication record was written as “5U” instead of “5 units.” A contribut- This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. ing factor to the insulin overdose identified by the in- 1—March 2005. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI & ISMP under contract to the Authority as stitution was the use of “U” for units. part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Through the USP-ISMP Medication Errors Reporting Copyright 2005 by the Patient Safety Authority. This publication may be re- Program (MERP), ISMP has also received a number printed and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their of reports where patients have received overdoses of entirety and without alteration provided the source is clearly attributed. insulin or heparin when “U” for unit has been used. In one report, a nurse who was taking a patient’s medi- To see other articles or issues of the Advisory, visit our web site at cation history recorded his insulin dose using the ab- www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Abbreviations: A Shortcut to Medication Errors (Continued) but the medication was given QD (every day). The The use of error-prone abbreviations and dose desig- patient received two extra doses before the error was nations has become a concern of the Joint Commis- discovered. sion on Accreditation of Healthcare Organizations (JCAHO). A National Patient Safety Goal (NPSG) in Other examples of reports including the use of error- 2004,3 the elimination of dangerous abbreviations has prone abbreviations submitted to PA-PSRS include: been carried over into the 2005 NPSG with two changes: (1) pre-printed forms are now included in • An elderly female patient received a Coumadin the scope of the goal, and (2) the goal now applies (warfarin) dose that should have been held be- only to orders (all orders) and other medication- cause her INR was 2.8. The original order stated related documentation, not all patient-specific docu- to give Coumadin if INR < 2.5 (less than 2.5). mentation.4,5 However, the “<” (less than) symbol was misinter- preted as “greater than,” and the patient was ad- To address the difficulty of achieving compliance with ministered Coumadin, despite the lack of sense in this NPSG, JCAHO offers several helpful tips.6 Most such an interpretation of the order. focus on educating, advocating, and reminding staff. One tip seems to be directly related to enforcement: • An elderly female patient received Vasotec “Direct pharmacy not to accept any of the prohibited (enalaprilat) 1.25 mg IV with a systolic blood abbreviations. Orders with dangerous abbreviations pressure less than 180 mmHg. The presciber’s or illegible handwriting must be corrected before be- order included a parameter to hold the medication ing dispensed.” A corollary to that—enlisting nurses if the patient’s “SBP<180.” However, the nurse to help notify physicians—may also be employed. confused the “<” and “>” signs and administered Unfortunately, following this advice has spurred nu- the medication when the patient’s systolic blood merous reports of burdensome workloads for those pressure measured only 140 mmHg. making the calls and strained relationships between the medical staff and nurses and pharmacists who • A physician wrote an illegible and confusing order are being forced to police the issue. to increase Diovan to 80 mg BID. An up arrow (↑) symbol was used to indicate “increase” but was The real issue is that enforcement of prohibited ab- read as the numeral 1. The pharmacy interpreted breviations requires more than asking pharmacists or the order to be Diovan 160 mg BID (since no 180 nurses to alert prescribers to lapses in compliance. mg form is available), and one dose of Diovan This is an organizational problem that requires peer- 160 mg was administered to the patient. Luckily to-peer interaction along with full support from hospi- she suffered no harm from this overdose. tal and medical staff leadership. Hospitals that have been working on this initiative relentlessly for years • A prescriber used an abbreviation for magnesium report that the most effective way to enforce physician sulfate and wrote “MgSo4 2g IV x 1 dose” for a compliance is to make it a physician-owned proc- 45-year-old female patient. However, the unit ess.7,8 When educational efforts failed to produce clerk and nurse misinterpreted the order as mor- significant change, these hospitals pursued opera- phine sulfate (MSO4) 2 mg IV x 1 dose, and the tional changes such as preprinted orders, targeted patient received a 2 mg dose of morphine sulfate. pages, and email reminders, to initially improve com- MSO4 is an error-prone abbreviation commonly pliance. Then, after enacting a zero tolerance policy, used in place of writing out morphine sulfate. medical staff leaders interacted with physicians who Contributing to this error was the fact that the pa- were noncompliant. Pharmacists and nurses still tient was having pain, so morphine seemed rea- played a role in collecting data about noncompliance, sonable. The prescriber was notified, and magne- and even notifying individuals when there was a lapse sium was administered to the patient. in policy. But the medical staff took responsibility and addressed all issues of repeated physician non- • An elderly patient was ordered Dilaudid compliance. (HYDROmorphone); however, the order was writ- ten without the use of leading zeroes (.2-.4 mg). In an effort to help increase compliance, JCAHO sur- As a result, the order was misread as 2-4 mg in- veyors in January were instructed to score prescrib- stead of the intended 0.2-0.4 mg. The nurse rec- ers’ use of any abbreviation on the National Patient ognized the error after giving the initial dose. The Safety Goal “dangerous - do not use” list as noncom- patient experienced no ill effects. pliance once the abbreviation is written on the chart.9 Facilities are no longer considered compliant if phar- Page 2 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Abbreviations: A Shortcut to Medication Errors (Continued) macists or nurses call a prescriber for clarification and Notes document the intended meaning. The goal is to place 1. ISMP. Medication Safety Alert! Acute Care Edition. 21 Oct 2004; responsibility for prescriber compliance on the medi- (9)21. cal and administrative staff instead of nurses and 2. ISMP. Medication Safety Alert! Community/Ambulatory Edition. pharmacists. Nov 2004;(3)11. 3. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). 2004 National Patient Safety Goals [online]. [cited 18 While it seems likely that this latest move will improve Feb 2005] Available from Internet: http://www.jcaho.org/ compliance, there are other strategies that facilities accredited+organizations/patient+safety/04+npsg/ can employ to help eliminate the use of dangerous index.htm#abbreviations abbreviations, such as: 4. JCAHO. Facts about the 2005 National Patient Safety [online]. [cited 18 Feb 12005] Available from Internet: http://www.jcaho.org/ accredited+organizations/patient+safety/ 05+npsg/npsg_facts.htm • Encouraging all hospital personnel including 5. JCAHO. 2005 National Patient Safety FAQs [online]. [cited 18 medical staff, pharmacists, and nurses to avoid Feb 12005] Available from Internet: http://www.jcaho.org/ using error-prone abbreviations in all written and accredited+organizations/patient+safety/05+npsg/ electronic communication. 05_npsg_faqs.htm#goal_3 6. JCAHO. Implementation Tips for Eliminating Dangerous Abbre- • Identifying and promoting “Physician Champions” viations [online]. [cited 18 Feb 12005] Available from Internet: who support accreditation-related activities and http://www.jcaho.org/accredited+organizations/ patient+safety/05+npsg/tips.htm advocate for full compliance with the NPSGs. 7. Traynor K. Enforcement outdoes education at eliminating unsafe abbreviations. Am J Health-Syst Pharm 2004; 16:1314-5. • Providing educational seminars and updates to all staff including the medical staff and administra- 8. Joint Commission Resources. A guide to JCAHO’s medication management standards. Oakbrook Terrace, IL: JCAHO; 2004. p. tors, and providing instruction to new staff and 142-6. residents before or at the beginning of their em- 9. ISMP. Medication Safety Alert! Acute Care Edition. 10 Feb 2005; ployment period. (10)3. • Disseminating posters and laminated cards with dangerous abbreviations and dose designations throughout the hospital and staff. • Removing any error-prone abbreviations from computerized prescriber order entry and other computer systems. • Avoiding use of abbreviations on computer- generated labels, labels for drug storage bins/ shelves, and in guidelines, charts, and protocols. Such steps are already being taken in many Pennsyl- vania facilities. Resources for Facilities ISMP List of Error-Prone Abbreviations, Symbols and Dose Designation—www.ismp.org/PDF/ ErrorProne.pdf JCAHO “Do not use” List—www.jcaho.org/ accredited+organizations/patient+safety/04+npsg/ index.htm#abbreviations) JCAHO Implementation Tips for Eliminating Danger- ous Abbreviations—www.jcaho.org/accredited+ or- ganizations/patient+safety/05+npsg/tips.htm ©2005 Pennsylvania Patient Safety Authority Page 3 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. Page 4 ©2005 Pennsylvania Patient Safety Authority