Study concludes abbreviations threaten patient safety

September 17, 2007

Use of abbreviations in health care leads to errors that jeopardize patient safety, according to a new study.

Nearly 5% of all reported medical errors between 2004 and 2006 were caused by abbreviations, 81% of which occurred during prescribing. The eight-page report, The Impact of Abbreviations on Patient Safety, analyzed nearly 30,000 medication error reports involving abbreviations and blames these errors for leading to 7,000 deaths annually.

One of the most common abbreviations threatening patient safety is the use of "qd" in place of "once daily."

More than three-quarters of the time, the abbreviations that result in medication errors come from doctors. Though nurses and pharmacists can also be the culprits, the study said these workers usually contact the doctor when abbreviations are confusing. "This often causes conflict between the healthcare professions, further deteriorating communication. Education targeted at illustrating the dangers of abbreviation use is essential."

Education is a start, but it may not be enough to eliminate the use of confusing abbreviations.

Surveys conducted by the Joint Commission last year revealed that 22% of accredited organizations were out of compliance with its "Do Not Use" list of abbreviations. Failing to comply with the list is fairly common, the Commission concluded.

Part of the reason for this noncompliance could be the training given to doctors and pharmacists. "We are taught and trained to use abbreviations," said Kasey Thompson, Pharm.D., director of patient safety at ASHP. "I can attest from my experience as a pharmacist that we were tested on abbreviations. It was part of my education. And it's just how health care is practiced. Part of your job is understanding what 'qid' stands for."

Hicks agrees, but, he said, "we are taught to abbreviate early in childhood," he noted. "In our e-mails we do a lot of abbreviating, we drop words, or we don't use the whole word. We've just been conditioned to abbreviate throughout our lives." To change that conditioning, Hicks suggests that doctors and other healthcare providers be trained to spell out medication orders.