Section 1: Making the Case

The use of communication shortcuts such as abbreviations, acronyms, and symbols puts patients at risk. Changes need to be made so that all patients benefit from clear communication about their medications and treatment plans.

Introduction

The use of abbreviations is a common practice in healthcare that is recognized to be unsafe. It will take more than an order writing policy or a list of abbreviations that are not to be used4 to change ingrained habits of communication. Practice change is a complex process. Time and a step-wise approach are needed to help healthcare providers adapt to new ways of communicating without using error-prone abbreviations. The first step is making a case for changing the way abbreviations are used.

When making a case:

  • Establish the importance of the abbreviation issue using the literature.
  • Define the problem in the local setting by gathering local evidence of current practices and reported problems related to abbreviation use.
  • Determine the desired outcome of the initiative – what will be different about how abbreviations are used if the initiative is a success?

Literature Summary

Abbreviations are a part of the culture of communication in healthcare

Historically, physicians, nurses, and pharmacists were taught to use Latin medical terms and their abbreviated forms when writing orders.5 The benefits of abbreviations seem obvious in today’s fast paced therapeutic environment – they are convenient, easy and quick to use, space saving, and hard to misspell.5

Abbreviations and acronyms are not universally understood

Some commonly understood abbreviations are a useful part of practice (e.g., ‘a.m.’ for morning or ‘AIDS’ for acquired immunodeficiency syndrome). Other abbreviations lead to misinterpretation of instructions if they have multiple meanings or are not understood by all healthcare providers (e.g., OD can mean ‘once a day’ or ‘right eye’ or ‘overdose’).5,6,7

Use of abbreviations is widespread

Abbreviations are found in medical treatment orders, prescriptions, medication administration records, care plans, clinical notes about the patient, and instructions to patients.7,8,9 Free text entry fields in the electronic medical record are open to short forms of communication.8 Texting abbreviations and acronyms are increasingly being found in audits of health records.10

Students learn to use abbreviations early

Classroom and clinical educators need to be aware of how abbreviation use is being modeled to students and new healthcare providers. Discourage students from using abbreviations and texting acronyms in their assignments and in all forms of professional communication including documenting in the patient health record.

Poor handwriting compounds the problem

Poor handwriting increases the risk associated with abbreviation use.11-14 In one study, 20 per cent of orders with error-prone abbreviations were deemed illegible.11 When illegible handwriting was a contributing factor to a medication error, the order often included an abbreviation.12, 13 Error-prone abbreviations can also be introduced when a verbal order is recorded or orders are copied onto a medication administration record.

Some abbreviations are more likely to result in errors

A small number of abbreviations were implicated in the majority of abbreviation-related errors reported to a national reporting system (Table 1).12

Table 1. Top five abbreviations associated with errors
Abbreviation Percentage of abbreviation-related errors
QD 43%
U 13%
cc 13%
MS04 or MS 10%
Leading or trailing zeros 4%

Adapted from Brunetti et al., 200712

Research documents the issue and impact of abbreviation use

Evidence from research on the impact of abbreviations will be useful in building a case for an abbreviation initiative. A summary of some of the research documenting the issues with abbreviation use is provided in the Resources at the bottom of this page.

Patient safety organizations urge limiting abbreviation use

Many patient safety organizations (Table 2) have identified specific error-prone abbreviations and recommend that steps be taken to limit or prohibit their use. Accreditation Canada has a Required Organizational Practice related to dangerous abbreviations.4 Most of these resources refer to the use of abbreviations in medication orders. However, there is a much broader scope of situations and types of documentation where the use of error-prone abbreviations should be eliminated.6 (Table 3)

Table 2. Patient safety organization resources
Organization Resource
Accreditation Canada Dangerous Abbreviations Required Organizational Practice4
Institute for Safe Medication Practices Canada (ISMP Canada) Do Not Use Dangerous Abbreviations, Symbols and Dose Designations15
Institute for Safe Medication Practices (ISMP) List of Error-Prone Abbreviations, Symbols and Dose Designations16
The Joint Commission Facts about the Official ‘Do Not Use’ List17
National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) Dangerous Abbreviations15
Australian Commission on Safety and Quality in Healthcare Recommendations for Terminology, Abbreviations and Symbols Used in the Prescribing and Administration of Medicines19



Table 3. Types of Communication where error-prone abbreviations should be eliminated20

Communication Type Examples
Prescriptions Handwritten
Electronic
Pre-printed prescriber order sets
Standing orders
Prescription labels
Transcribed orders Verbal orders
Medication administration records
Medication reconciliation – best possible medication history form
Clinical communication Progress notes
Multi-disciplinary notes
Emergency department visit records
Discharge and transfer summaries
Operative notes
Protocols and care maps
Electronic medical or health records E-prescribing or computerized prescriber order entry
Free text entries in encounter notes or prescription notes
Published medical information Style guidelines include abbreviations not to be used
Research articles
Journals
Manuals
Pharmaceutical industry communications Promotional advertising including graphics and text
Training materials, presentations
Packaging and labelling
Education institutions/continuing education programs Instructional materials
Textbooks
Computer systems used in laboratories or practice settings
Publications
Communications with or instructions to students in small teaching groups

Local Context

In addition to evidence from the literature, an improvement initiative is more likely to be successful if it addresses a documented problem in the local setting. For example, is there an error-prone abbreviation that is frequently used or that has been a contributing factor in patient safety incidents? How are abbreviations used in high risk situations where misinterpretation could have significant consequences for the patient? More information about specific high risk situations – high alert medications, abbreviated medication names, and pediatrics – can be found here.

To focus the abbreviation initiative, define the local problem and relate it to what is known about the impact of abbreviations from the literature. This will help build a case for an executive sponsor (Engaging the Right People). Some questions that can be used to guide collection of information to help define local practice patterns are presented in Table 4. Sources of information about abbreviation use may include:

  • Patient health records – particularly medication and treatment orders, clinical notes, and records of treatments given (e.g., medication administration records)
  • Order sets (e.g., pre-printed forms or electronic documents)
  • Reports of patient safety incidents or close calls involving abbreviations
  • Medication or treatment orders with abbreviations that require clarification with the prescriber

Gather information by reviewing records from a specific time period in the past, or by noting abbreviations as they are currently being used. Although data from the local setting will be most relevant, consider trying to find information from similar organizations or programs if possible. Comparative data may also be found in the literature.

Table 4. Questions to help define local practice patterns
  • What abbreviations are most commonly used in the setting?
  • What abbreviations are used with high alert medications (e.g., insulin, warfarin, narcotics)?
  • What abbreviations have been implicated in patient safety incidents?
  • Who is using abbreviations (e.g., doctor, nurse, pharmacist, other healthcare provider)?
  • How are abbreviations being used (e.g., to order treatments, document patient progress, transcribe treatment orders, give instructions to patients)?
  • What abbreviations are commonly used for each purpose?
  • What is the impact of abbreviation use (e.g., orders need to be clarified; abbreviation results in a close call or error, such as a transcription error or patient receiving an incorrect dose of medication)?

U for Units: Identifying a Local Problem

In preparation for accreditation, a hospital pharmacy reviewed abbreviation use in all medication orders received over a one-month period. Staff recorded any abbreviations used that did not comply with the hospital medication order writing policy, as well as the patient care area where the order originated.

The pattern of most concern was use of the abbreviation U for units. The use was particularly high on one medical and one surgical unit. Eight medication errors related to the use of U for prescribing insulin had been documented in the previous year. Further investigation into how U was being used found that it was commonly used by both nurses and doctors in documenting care in the patient health record.

See Full Case

U for Units: Identifying a Local Problem

In preparation for accreditation, the Director of Care of a long term care facility asked the pharmacy service provider to review abbreviation use in all medication orders received over a six week period. Pharmacy staff recorded any abbreviations used that did not comply with the facility’s medication order writing policy.

The pattern of most concern was use of the abbreviation U for units when insulin was ordered. The Director of Care also reviewed medication errors from the past year, focusing on those that involved abbreviations. Four medication incidents related to the use of U for designating a dose of insulin had been documented in the previous year. Two of these involved misinterpretation of a physician order and two involved use of U during transcription – one concerned a verbal order transcribed into the resident’s chart/physician orders and the other occurred when a new insulin dose was transcribed onto the medication administration record by a nurse.

See Full Case

Desired Outcomes

What is the desired outcome of the initiative?

The desired outcome of the initiative describes what the future state of abbreviation use in the local setting will look like if the initiative is successful. A goal will be more likely to be achieved if it is focused on a local problem demonstrated to be important. Goals should be SMART:

  • Specific
  • Measurable
  • Achievable
  • Realistic and relevant for the setting, and
  • Time-bound (a time frame to achieve the outcome is established)

U for Units: Establishing an Outcome

The Pharmacy Manager developed a proposal for an abbreviation initiative that would target the use of U instead of units in medication ordering. Although the use of U for units in charting was also recognized as an issue, it was felt that it would be most productive to focus on medication ordering first.

The stated desired outcome of the initiative was that in twelve months the word units rather than U would be used to specify the dosage of appropriate medications in all medication orders. The Pharmacy Manager realized this was an ambitious goal but felt that anything less posed an unacceptable safety risk to patients.

See Full Case

U for Units: Establishing an Outcome

Together the Director of Care and the consultant pharmacist developed a proposal for an abbreviation initiative that would target the use of U instead of units in medication ordering and charting of insulin.

The stated desired outcome of the initiative was that in twelve months the word units rather than U would be used to specify the insulin dosage in all medication orders and transcriptions of medication orders for insulin. They realized this was an ambitious goal but felt that anything less posed an unacceptable safety risk to patients.

See Full Case

Resources

  • More in-depth review of the literature from which the summary information was abstracted. Includes a complete reference list for the Abbreviations Toolkit.

  • Table summarizing selected research that documents the problems with abbreviation use in healthcare.

  • Overview of the issues when abbreviations are used to communicate about insulin, anticoagulants, digoxin, and narcotics.

  • Overview of the issues association with abbreviating medication names, using acronyms, and confusion with suffixes used to distinguish between formulations.

  • Overview of issues related to using abbreviations to communicate about medications in pediatrics and specific concerns related to correct dosing of liquid preparations.