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U cnt abbrv “Patient Safety”



From the April 3, 2003 issue


Now that the Joint Commission’s 2003 National Patient Safety Goals (NPSGs) are in effect, some practitioners are asking if evidence exists to support the effectiveness of the new requirements. In particular, some hospitals are having trouble getting staff to avoid using selected abbreviations that we and others consider to be dangerous. Actually, we are unaware of studies that demonstrate the degree of risk with using these abbreviations, or the effectiveness of avoiding their use in preventing medication errors. Such studies are difficult to mount, and it’s doubtful that an institutional review board would approve a study with a control group due to obvious ethical considerations. However, we CAN affirm that the dangerous abbreviations that we’ve published previously have been involved in harmful, even fatal, medication errors.

Absent scientific research to prove its effectiveness, the evidence for this error reduction strategy is nonetheless obvious. Similar to removing potassium chloride concentrate vials from patient care areas and providing timely pharmacy distribution of solutions, you don’t need scientific validation to prove that such action will prevent the drug from being given IV push. Similarly, we have enough obvious evidence that using “U” for “units” has led to countless tenfold overdoses of insulin, heparin, and penicillin G (including an infant death from hyperkalemia).

In discussing the dilemma between evidence-based medicine and obvious patient safety strategies, Leape, Berwick, and Bates1 noted that, “A common theme... is that they make sense. To a lay person and to most physicians these things sound like obvious things to do. That is basically how aviation and anesthesia made progress: they did what seemed to be the obvious right thing to do.”

Certainly, ISMP and JC are not the only patient safety organizations that suggest avoiding abbreviations and dose expressions that have led to serious medication errors. In 1997, the National Coordinating Council for Medication Error Reporting and Prevention (www.NCCMERP.org), comprised of 20 nationally recognized organizations, published a list of dangerous abbreviations that should be avoided. Several healthcare standards organizations have eliminated these abbreviations from their style manuals or, in the case of USP, from its official compendium. FDA will not permit their use with drug package labeling. The National Quality Forum Safe Practices Steering Committee also recommends avoiding abbreviations and dose expressions deemed to be dangerous (www.qualityforum.org).

With the Joint Commission’s NPSGs, a list of specific abbreviations to avoid is not dictated; rather, hospitals are required to compile a list and take action to avoid their use. So to begin, focus on the relatively few abbreviations that are most likely to cause harm. Keep in mind, though, that this error reduction strategy should not be undertaken solely because of a compliance imperative. Instead, healthcare providers should be willing to make such a relatively minor change in their practice to eliminate the risk of harming a patient. Isn’t that what a commitment to patient safety is all about…our willingness to change practices if it results in patient safety? Our patients have come to expect it, and they deserve nothing less.

Reference 1. Leape LL, Berwick DM, Bates DW. What practices will most increase safety?: Evidence-based medicine meets patient safety. JAMA 2002;288:501-7.

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