JCAHO reconsiders abbreviation protocols

March 7, 2005

The Joint Commission on Accreditation of Healthcare Organizations has backtracked on its prohibition against the use of potentially unsafe abbreviations. Rather than eliminating the use of QD (daily), U (units), and other shortcuts within the organizations it surveys, JCAHO is pushing to restrict abbreviation use in handwritten, preprinted, or in free text entry of patient care and medication records.

The Joint Commission on Accreditation of Healthcare Organizations has backtracked on its prohibition against the use of potentially unsafe abbreviations. Rather than eliminating the use of QD (daily), U (units), and other shortcuts within the organizations it surveys, JCAHO is pushing to restrict abbreviation use in handwritten, preprinted, or in free text entry of patient care and medication records.

The change grew out of a consensus summit on unsafe abbreviations held in November 2004. Fifty groups, representing pharmacy, hospitals, physicians, nursing, and other healthcare interests, debated JCAHO's original National Patient Safety Goal (NPSG) that called for the complete and immediate elimination of many common abbreviations.

"We had what we believed was a reasonable requirement to improve patient safety," said Richard Croteau, M.D., JCAHO's executive director for strategic initiatives. But it is not that easy for practitioners to change what they have practiced throughout their careers, even though they recognize the potential risk to patients, he said.

JCAHO called a similar summit several years ago when surgeons resisted new requirements aimed at reducing wrong-site surgery, Croteau said. The result was a universal protocol that requires surgeons to identify and sign surgery sites before patients enter the operating room, in order to reduce confusion and surgical errors.

"The Joint Commission recognized that requiring such a shift in the use of abbreviations was a major cultural shift for medical departments, physicians, and pharmacists," said Kasey Thompson, director of ASHP's Center on Patient Safety. "It recognized the need to lay out the evidence to everyone with an interest in the outcome."

Pharmacy had a vital interest in abbreviations, Thompson noted. As the requirement was originally written, the NPSG made pharmacy responsible for eliminating abbreviations. Pharmacists were expected to call physicians on every inappropriate abbreviation and, except in emergencies, reject drug orders that used banned abbreviations. Physicians would have to rewrite and resubmit the offending orders before they could be filled.

"Pharmacy departments are important in eliminating abbreviations, but it is irresponsible to expect pharmacists to act as a police force," Thompson contended. "It's an organization issue," he said.

"The Joint Commission did something important here in bringing stakeholders together to forge a consensus," Thompson said. Now we can move forward in eliminating these known sources of potential error that endanger patient safety."

JCAHO's list of prohibited abbreviations is based largely on case studies and recommendations from the Institute for Safe Medication Practices. ISMP has compiled a list of more than 60 commonly used abbreviations, symbols, and dose designations that have been implicated in medication errors.The most common problem is q.d. or QD, said ISMP president Michael Cohen. Although q.d. means "every day," it is easily mistaken for q.i.d. (four times a day). (See ISMP's list of dangerous abbreviations at http:// http://www.ismp.org/PDF/ErrorProne.pdf)

"We have been promoting a long list of abbreviations that should never be used because they are so dangerous," Cohen told Drug Topics. "How much longer does it take to write d-a-i-l-y on an order instead of q.d. in the cause of safety? Why risk anything unnecessary when you're dealing with patients?" The answer is, of course, habit and institutional inertia.