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.
