Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation

Interpretation and Misinterpretation of Medical Abbreviations Found in Patient Medical Records: A Cross-Sectional Survey

Introduction  Medical abbreviations are used in patient medical records across all departments within the hospital setting and upon discharge. Abbreviations can have more than one contradictory or ambiguous definition, which can result in errors in communication due to misunderstanding or misinterpretation. Modern patient care is multidisciplinary, so there should be no room for ambiguity in patient medical records. Therefore, the aim of this survey was to assess individual interpretations and misinterpretations of a list of medical abbreviations found in patient medical records, and thereby increase awareness of the growing use of non-standard abbreviations.  Materials and methods  In this cross-sectional survey, anonymized questionnaires containing a list of 20 abbreviations were given to a convenience sample of consultant physicians, doctors-in-training, and nurses, all of whom are involved in the day-to-day use of patient medical records. Volunteers were asked to define each abbreviation in full. A provided definition was either the intended definition (given a score of one) or completely different in terms of text and meaning (alternative definition). The intended definitions, alternative definitions, and number of abbreviations that were defined by at least 50% of volunteers were collated. Abbreviations that had more than 50% of volunteers providing the intended definition, were regarded as "generally accepted" abbreviations. Volunteers were assured that this was not a test of knowledge and that questionnaires were completely anonymized.  Results  In total, 46 volunteers completed questionnaires. Volunteers consisted of 15 nurses, 15 doctors-in-training, and 16 consultant physicians. The number of volunteers who provided the intended definition for each abbreviation ranged from zero to 87%, depending on the abbreviation. Only four out of 20 abbreviations (20%) had more than 50% of volunteers providing the intended definition and thus regarded as "generally accepted". The maximum score achieved among the volunteers was 12 out of 20 (60%), and the minimum score achieved was 2 out of 20 (10%). The overall mean score achieved by the volunteers was 6.39 out of 20 (32%). Only one-quarter of the volunteers achieved a score above 50%. Additionally, 75% of the abbreviations had one or more (one to seven) alternative definitions.  Conclusions  This survey demonstrated that non-standard medical abbreviations used in patient medical records were being misunderstood or misinterpreted. A majority of abbreviations were not recognized among user groups. Additionally, three-quarters of abbreviations had one or more alternative definitions. Healthcare institutions should encourage the reporting of errors arising from the usage of abbreviations, and introduce initiatives to discourage the use of non-standard abbreviations in patient medical records.

The impact of a computerized physician order entry system implementation on 20 different criteria of medication documentation-a before-and-after study

Background

The medication process is complex and error-prone. To avoid medication errors, a medication order should fulfil certain criteria, such as good readability and comprehensiveness. In this context, a computerized physician order entry (CPOE) system can be helpful. This study aims to investigate the distinct effects on the quality of prescription documentation of a CPOE system implemented on general wards in a large tertiary care hospital.

Methods

In a retrospective analysis, the prescriptions of two groups of 160 patients each were evaluated, with data collected before and after the introduction of a CPOE system. According to nationally available recommendations on prescription documentation, it was assessed whether each prescription fulfilled the established 20 criteria for a safe, complete, and actionable prescription. The resulting fulfilment scores (prescription-Fscores) were compared between the pre-implementation and the post-implementation group and a multivariable analysis was performed to identify the effects of further covariates, i.e., the prescription category, the ward, and the number of concurrently prescribed drugs. Additionally, the fulfilment of the 20 criteria was assessed at an individual criterion-level (denoted criteria-Fscores).

Results

The overall mean prescription-Fscore increased from 57.4% ± 12.0% (n = 1850 prescriptions) before to 89.8% ± 7.2% (n = 1592 prescriptions) after the implementation (p < 0.001). At the level of individual criteria, criteria-Fscores significantly improved in most criteria (n = 14), with 6 criteria reaching a total score of 100% after CPOE implementation. Four criteria showed no statistically significant difference and in two criteria, criteria-Fscores deteriorated significantly. A multivariable analysis confirmed the large impact of the CPOE implementation on prescription-Fscores which was consistent when adjusting for the confounding potential of further covariates.

Conclusions

While the quality of prescription documentation generally increases with implementation of a CPOE system, certain criteria are difficult to fulfil even with the help of a CPOE system. This highlights the need to accompany a CPOE implementation with a thorough evaluation that can provide important information on possible improvements of the software, training needs of prescribers, or the necessity of modifying the underlying clinical processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01607-6.

Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback

Background Hospital pharmacy audit and feedback of 'do not use' medication abbreviations improves patient safety. For audit and feedback systems to be effective, the data captured must be of high quality such that end-users trust the information to guide practice change. The quality of data captured during monthly standardized pharmacy 'do not use' abbreviation audits is currently unknown. Objective We aimed to assess pharmacy 'do not use' abbreviation audit data quality. Method Primary audit data quality was assessed by examining a random sample of handwritten medication prescriptions for the presence and type of 'do not use' abbreviations. This data was compared with the pharmacy monthly audit data to determine data capture agreement and consistency over time. Results There were 1132 prescriptions from July, October, and December 2019 included. Data capture agreement between the pharmacy audit and the secondary assessment using Cohen's Kappa ranged from 0.53 to 0.63. The primary audit under-reported 'do not use' abbreviation rates, however this did not vary over time (χ2 = 1.215, p = 0.545). Conclusion Pharmacy staff audits under-reported 'do not use' abbreviation rates, however this was consistent over time. The quality of pharmacy audits should be assessed and disseminated to end-users prior to implementing feedback.

A content analysis of documentation on communication disability in hospital progress notes: diagnosis, function, and patient safety

Objective:

To examine the content, quantity, and quality of multidisciplinary team documentation of ‘communication’ in hospital progress notes of patients with communication disability, and to explore the relationship of this documentation to patient safety.

Design:

Retrospective chart review involving a descriptive analysis and a qualitative content analysis of the progress notes.

Setting:

Acute medical and rehabilitation wards in two regional hospitals in one health district in Australia.

Participants:

Eight patients with communication disability who had experienced documented patient safety incidents in hospital.

Methods:

In total, 906 progress note entries about communication during 38 hospital admissions were extracted from eight patient’s charts; written by staff in 11 different health disciplines. Data were analysed descriptively according to quantity, and qualitatively according to the content.

Results:

Four content categories of meaning in progress note entries relating to communication were (1) use of communication diagnostic and impairment terms; (2) notes on the patient’s communicative function; (3) reports of the topic or content of the patient’s communication attempts; and (4) references to third parties communicating for the patient. Communication-related information was often brief, unclear, and/or inaccurate. Descriptions of communicative function and recommended strategies for successful communication were often lacking.

Conclusion:

The suboptimal documentation of patient communication in progress notes may contribute to the higher risk of patient safety incidents for hospital patients with communication disability. Increased accuracy in documenting communication disability and function in progress notes might assist staff in communicating with these patients and improve the quality and safety of their care.

Reducing adverse medication events in mental health: Australian National Survey

AIM

To determine the extent to which evidence-based medication safety practices have been implemented in public and private mental health inpatient units across Australia.

METHODS

The Reducing Adverse Medication Events in Mental Health survey was piloted in Victoria, Australia, in 2015, and rolled out nationally in 2016. In total, 235 mental health inpatient units from all States and Territories in Australia were invited to participate. The survey included questions about the demographics of the mental health unit, evidence-based strategies to improve prescription writing, the administration and dispensing of medicines and pharmacy-led interventions, and also questions relating to consumer engagement in medication management and shared decision-making.

RESULTS

The response rate was 45% (N = 106 units). Overall, the survey found that 57% of the mental health units had fully or partially implemented evidence-based medication safety practices. High levels of implementation (80%) were reported for the use of standardized medication charts such as the National Inpatient Medication Chart as a way to improve medication prescription writing. Most (71%) of the units were using standardized forms for recording medication histories, and 56% were using designated forms for Medication Management Plans. However, less than one-fifth of the units had implemented electronic medication management systems, and the majority of units still relied on paper-based documentation systems.Interventions to improve medicine administration and dispensing were not highly utilized. Individual patient-based medication distribution systems were fully implemented in only 9% of the units, with a high reliance (81%) on ward stock or imprest systems. Tall Man lettering for labelling was implemented in only one-third of the units.Pharmacy services were well represented in mental health units, with 80% having access to onsite pharmacist services providing assessments of current medications and clinical review services, adverse drug reaction reporting and management services, patient and carer education and counselling, and medicines information services. However, pharmacists were involved in only half of medical reconciliations. Their involvement in post-discharge follow-up was limited to 4% of units.

CONCLUSIONS

Gaps in medication safety practices included limited use of individual patient supply systems for medication distribution, a high reliance on ward stock systems and high reliance on paper-based systems for medication prescribing and administration. With regards to service provision, clinical pharmacist involvement in medical reconciliation services, therapeutic drug monitoring and interdisciplinary ward rounds should be increased. Discharge and post-discharge services were major gaps in service provision.

Frequency, comprehension and attitudes of physicians towards abbreviations in the medical record

AIMS

Abbreviations are common in the medical record. Their inappropriate use may ultimately lead to patient harm, yet little is known regarding the extent of their use and their comprehension. Our aim was to assess the extent of their use, their comprehension and physicians' attitudes towards them, using ophthalmology consults in a tertiary hospital as a model.

METHODS

We first mapped the frequency with which English abbreviations were used in the departments' computerised databases. We then used the most frequently used abbreviations as part of a cross-sectional survey designed to assess the attitudes of non-ophthalmologist physicians towards the abbreviations and their comprehension of them. Finally, we tested whether an online lecture would improve comprehension.

RESULTS

4375 records were screened, and 235 physicians responded to the survey. Only 42.5% knew at least 10% of the abbreviations, and no one knew them all. Ninety-two per cent of respondents admitted to searching online for the meanings of abbreviations, and 59.1% believe abbreviations should be prohibited in medical records. A short online lecture improved the number of respondents answering correctly at least 50% of the time from 1.2% to 42% (P<0.001).

CONCLUSIONS

Abbreviations are common in medical records and are frequently misinterpreted. Online teaching is a valuable tool for physician education. The majority of respondents believed that misinterpreting abbreviations could negatively impact patient care, and that the use of abbreviations should be prohibited in medical records. Due to low rates of comprehension and negative attitudes towards abbreviations in medical communications, we believe their use should be discouraged.

Audit on the Use of Dangerous Abbreviations, Symbols, and Dose Designations in Paper Compared to Electronic Medication Orders: A Multicenter Study

BACKGROUND

Dangerous abbreviations on the Institute for Safe Medication Practices Canada's "Do Not Use" list have resulted in medication errors leading to harm. Data comparing rates of use of dangerous abbreviations in paper and electronic medication orders are limited.

OBJECTIVE

To compare rates of use of dangerous abbreviations from the "Do Not Use" list, in paper and electronic medication orders. Secondary objectives include determining the proportion of patients at risk for medication errors due to dangerous abbreviations and the most commonly used dangerous abbreviations.

METHODS

One-day cross-sectional audits of medication orders were conducted at a 6-site hospital network in Toronto, Canada, between December 2013 and January 2014. Proportions of paper and electronic medication orders containing dangerous abbreviation(s) were compared using a χ² test. The proportion of patients with at least 1 medication order containing dangerous abbreviation(s) and the top 5 dangerous abbreviations used were described.

RESULTS

Overall, 255 patient charts were reviewed. The proportions of paper and electronic medication orders containing dangerous abbreviation(s) were 172/714 (24.1%) and 9/2207 (0.4%), respectively ( P < 0.001). Almost one-third of patients had medication order(s) containing dangerous abbreviation(s). The proportions of patients with at least 1 medication order during the audit period containing dangerous abbreviation(s) for patients with paper only, electronic only, or a hybrid of paper and electronic medication orders were 50.5%, 5%, and 47.2%, respectively. Those most commonly used were "D/C", drug name abbreviations, "OD," "cc," and "U."

CONCLUSIONS

Electronic medication orders have significantly lower rates of dangerous abbreviation use compared to paper medication orders.

Mutual comprehension of urological abbreviations

Objective:

To establish the comprehension of urological abbreviations by non-urologists, and evaluate the awareness of urologists to this issue.

Subjects and methods:

This study involved complimentary surveys to non-urologists and urologists in the same area. The non-urologist survey was distributed to three groups: medical students, junior doctors, GPs and GP trainees. It assessed the comprehension of 24 commonly used urological abbreviations. The urologists’ survey assessed the urologists’ expectations of comprehension by each of the non-urologist groups. A total of 196 non-urologists (19 medical students, 35 junior doctors and 142 GPs and GP trainees), and 11 urologists and urological trainees participated.

Results:

On average the junior doctors and GPs understood approximately the same number of abbreviations (9.86 and 9.62 correct, respectively), with the medical students understanding fewer (7.89 correct). While this difference was statistically significant (F2,193df=3.875, P=0.022), gender, number of years post-graduation and completion of a urology term were not shown to have an impact on the comprehension of urological abbreviations. Of the 24 abbreviations, nine were correctly understood by more than 50% of non-urologists. The urologists did not expect non-urologists to understand a majority of the abbreviations; however, most also reported not using abbreviations routinely in communications with non-urologists.

Conclusions:

These results suggest that caution must be used when using abbreviations in communication with non-urologists as there is a high chance of the recipient not understanding the abbreviations. This is particularly pertinent given the current rollout of electronic medical records across Australia.

Overview of shorthand medical glossary (OMG) study

BACKGROUND

Shorthand is commonplace in clinical notation. While many abbreviations are standard and widely accepted, an increasing number are non-standard and/or unrecognisable.

AIM

We sought to describe the frequency of inappropriate and ambiguous shorthand in discharge summaries.

METHODS

Eighty electronic discharge summaries from the four General Medical Units at the Royal Melbourne Hospital were randomly extracted from the hospital's electronic records. Extraction was stratified by the four units and by the four quarters between July 2012 and June 2013. All abbreviations were assigned into one of four categories according to appropriateness: 1. 'Universally accepted and understood even without context'; 2. 'Understood when in context'; 3. 'Understood but inappropriate and/or ambiguous'; and 4. 'Unknown'. These categories were determined by the authors, which included junior and senior medical staff.

RESULTS

The 80 discharge summaries contained 840 different abbreviations used on 6269 occasions. Of all words, 20.1% were abbreviations. Of the 6269 occasions of shorthand, 6.8% were categorised as 'Understood but inappropriate and/or ambiguous' or 'Unknown' (category 3 or 4), equating to 1.4% of all words, and an average of 5.4 words per discharge summary.

CONCLUSION

Abbreviations are common in electronic discharge summaries, occurring at a frequency of one in five words. While the majority of shorthand used seems to be appropriate, the use of inappropriate, ambiguous or unknown shorthand is still frequent. This has implications for safe and effective patient care and highlights the need for better awareness and education regarding use of shorthand in clinical notation.

An Observational Study of the Impact of a Computerized Physician Order Entry System on the Rate of Medication Errors in an Orthopaedic Surgery Unit

Aim

To assess the impact of the implementation of a Computerized Physician Order Entry (CPOE) associated with a pharmaceutical checking of medication orders on medication errors in the 3 stages of drug management (i.e. prescription, dispensing and administration) in an orthopaedic surgery unit.

Methods

A before-after observational study was conducted in the 66-bed orthopaedic surgery unit of a teaching hospital (700 beds) in Paris France. Direct disguised observation was used to detect errors in prescription, dispensing and administration of drugs, before and after the introduction of computerized prescriptions. Compliance between dispensing and administration on the one hand and the medical prescription on the other hand was studied. The frequencies and types of errors in prescribing, dispensing and administration were investigated.

Results

During the pre and post-CPOE period (two days for each period) 111 and 86 patients were observed, respectively, with corresponding 1,593 and 1,388 prescribed drugs. The use of electronic prescribing led to a significant 92% decrease in prescribing errors (479/1593 prescribed drugs (30.1%) vs 33/1388 (2.4%), p < 0.0001) and to a 17.5% significant decrease in administration errors (209/1222 opportunities (17.1%) vs 200/1413 (14.2%), p < 0.05). No significant difference was found in regards to dispensing errors (430/1219 opportunities (35.3%) vs 449/1407 (31.9%), p = 0.07).

Conclusion

The use of CPOE and a pharmacist checking medication orders in an orthopaedic surgery unit reduced the incidence of medication errors in the prescribing and administration stages. The study results suggest that CPOE is a convenient system for improving the quality and safety of drug management.

The effectiveness of a 'Do Not Use' list and perceptions of healthcare professionals on error-prone abbreviations

BACKGROUND

The use of error-prone abbreviations has led to medication errors. Many safety organisations have introduced 'Do Not Use' lists (lists of error-prone abbreviations that should be avoided by prescribers), but the effectiveness of these lists have not been studied.

OBJECTIVE

We assessed the effectiveness of the 'Do Not Use' list introduced to the study hospital, and sought the attitudes of healthcare professionals on other potentially dangerous abbreviations (not included in the 'Do Not Use' list) used in prescriptions.

SETTING

The study was conducted in a university affiliated tertiary hospital in Hong Kong.

METHODS

An uncontrolled observational study was conducted. In-patient prescriptions were reviewed to assess the use of error-prone abbreviations included in the 'Do Not Use' list before, after its introduction, and following the first reinforcement. An on-line survey was also conducted among prescribers, pharmacists and nurses.

MAIN OUTCOME MEASURE

Rate of using error-prone abbreviations and other unapproved abbreviations among reviewed prescriptions.

RESULTS

3,238 prescriptions (23,398 drug items) were reviewed. The use of abbreviations in the 'Do Not Use' list decreased from 7.8 to 3.3 % after its introduction (P < 0.001) and to 1.3 % after the first reinforcement (P < 0.001). However, unapproved abbreviations were used to denote prescribing instructions in 19.2 % of the drugs prescribed. 49 different types of unapproved abbreviations were used for drug names.

CONCLUSIONS

A 'Do Not Use' list is effective in reducing error-prone abbreviations. Reinforcements of the 'Do Not Use' list further improves prescriber adherence. However, many other unapproved abbreviations (not included in current 'Do Not Use' lists) are used when prescribing. Periodic reminders on error-prone abbreviations and education of prescribers on associated risks may help to reduce the use of error-prone abbreviations in hospitals.