Revista de enfermería y cuidados

Medication Errors: Medication Orders with Error-Prone Abbreviations

Abstract

Hana Morrissey and Patrick Ball

Introduction: Ambiguous abbreviations are one the most common and preventable causes of medication errors. Clinicians use many abbreviations as a timesaving convenience; however they can be prone to misinterpretation. Aim: The aim of this practice review evaluation is to identify the top six error-prone abbreviations at a local Hospital and compare those results to previous review conducted at the same facility to detect any improvement in practice. Method: Copies of inpatient medication charts were randomly selected from each ward over a one-week period. A sample size of 100 patients’ charts was included in the audit. Only regular orders on all current medication charts were included in the review (excluding ceased orders). The audit tool used is based on indicator 3.3, “Percentage of medication orders that include error-prone abbreviations” published by the New South Wales, Australia; Therapeutic Advisory Group. Findings: A total of 47 error-prone abbreviations were detected which equates to an overall incidence of 6% (n=784 medication orders) which is higher than the results of the audits of 2008 (5.1%) and 2012 (5.3%). The most common error-prone abbreviation were ‘mcg or ug’ (57.4%), ‘od or OD’ (23.4%) and ‘U or IU’ (19.1%). There were no ‘leading zeros’, ‘trailing zeros’ or ‘qd or QD’ abbreviation in the sample audited. Conclusion: The audit suggests that the possible reasons for the increase in use of unapproved abbreviations may include: 1) junior medical officers were not instructed to use the New South Wales, Australia, Therapeutic Advisory Group guidelines or 2) some medical staff are in the habit of using varying abbreviations due to their previous work experience and practice standards. If these doctors had never received timely or direct feedback on their prescribing practices then they may not be aware that they are utilising error-prone abbreviations.