1
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Parry D, Odedra A, Fagbohun M, Oeppen RS, Davidson M, Brennan PA. Abbreviation use decreases effective clinical communication and can compromise patient safety. Br J Oral Maxillofac Surg 2023; 61:509-513. [PMID: 37563053 DOI: 10.1016/j.bjoms.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/16/2023] [Indexed: 08/12/2023]
Abstract
Clear communication is paramount for achieving the safest and best patient outcomes, for maximising time efficiency, and lowering clinician workload. Multiple factors contribute to communication efficacy, including knowledge of topics between those communicating, interpersonal familiarity, and available time. Information exchange is growing faster and more frequent due to evolving communication technology, and communication is expanding as a response to increasing workloads. The number of referrals between specialties and the general practitioner (GP) is rising. The use of abbreviations has expanded in clinical communications and is likely to lead to misunderstanding, increased workload, and worse patient outcomes. In this article, we explore the use of abbreviations in the clinical setting.
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Affiliation(s)
- D Parry
- King's College London, Hodgkin Building, London SE1 1UL, United Kingdom.
| | - A Odedra
- Colchester General Hospital, Colchester CO4 5JL, United Kingdom.
| | - M Fagbohun
- The Park Practice, 17 Oakfield Road, London SE20 8QA, United Kingdom.
| | - R S Oeppen
- University Hospitals, Southampton SO16 6YD, United Kingdom.
| | | | - P A Brennan
- Queen Alexandra Hospital, Porstmouth PO6 3LY, United Kingdom.
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2
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Jayatilake DC, Oyibo SO. Interpretation and Misinterpretation of Medical Abbreviations Found in Patient Medical Records: A Cross-Sectional Survey. Cureus 2023; 15:e44735. [PMID: 37674765 PMCID: PMC10479966 DOI: 10.7759/cureus.44735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2023] [Indexed: 09/08/2023] Open
Abstract
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.
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Affiliation(s)
| | - Samson O Oyibo
- Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR
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3
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Hossain E, Rana R, Higgins N, Soar J, Barua PD, Pisani AR, Turner K. Natural Language Processing in Electronic Health Records in relation to healthcare decision-making: A systematic review. Comput Biol Med 2023; 155:106649. [PMID: 36805219 DOI: 10.1016/j.compbiomed.2023.106649] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/04/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Natural Language Processing (NLP) is widely used to extract clinical insights from Electronic Health Records (EHRs). However, the lack of annotated data, automated tools, and other challenges hinder the full utilisation of NLP for EHRs. Various Machine Learning (ML), Deep Learning (DL) and NLP techniques are studied and compared to understand the limitations and opportunities in this space comprehensively. METHODOLOGY After screening 261 articles from 11 databases, we included 127 papers for full-text review covering seven categories of articles: (1) medical note classification, (2) clinical entity recognition, (3) text summarisation, (4) deep learning (DL) and transfer learning architecture, (5) information extraction, (6) Medical language translation and (7) other NLP applications. This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULT AND DISCUSSION EHR was the most commonly used data type among the selected articles, and the datasets were primarily unstructured. Various ML and DL methods were used, with prediction or classification being the most common application of ML or DL. The most common use cases were: the International Classification of Diseases, Ninth Revision (ICD-9) classification, clinical note analysis, and named entity recognition (NER) for clinical descriptions and research on psychiatric disorders. CONCLUSION We find that the adopted ML models were not adequately assessed. In addition, the data imbalance problem is quite important, yet we must find techniques to address this underlining problem. Future studies should address key limitations in studies, primarily identifying Lupus Nephritis, Suicide Attempts, perinatal self-harmed and ICD-9 classification.
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Affiliation(s)
- Elias Hossain
- School of Engineering & Physical Sciences, North South University, Dhaka 1229, Bangladesh.
| | - Rajib Rana
- School of Mathematics, Physics and Computing, University of Southern Queensland, Springfield Central QLD 4300, Australia
| | - Niall Higgins
- School of Management and Enterprise, University of Southern Queensland, Darling Heights QLD 4350, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD 4000, Australia; Metro North Mental Health, Herston QLD 4029, Australia
| | - Jeffrey Soar
- School of Business, University of Southern Queensland, Springfield Central QLD 4300, Australia
| | - Prabal Datta Barua
- School of Business, University of Southern Queensland, Springfield Central QLD 4300, Australia
| | - Anthony R Pisani
- Center for the Study and Prevention of Suicide, University of Rochester, Rochester, NY, United States
| | - Kathryn Turner
- School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD 4000, Australia
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Mohd Sulaiman I, Bulgiba A, Abdul Kareem S. Prevalence and Risk Factors for Dangerous Abbreviations in Malaysian Electronic Clinical Notes. Eval Health Prof 2023; 46:41-47. [PMID: 36444613 DOI: 10.1177/01632787221142623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where English is widely used, and elicit the risk factors associated with dangerous abbreviations. We randomly sampled and manually annotated 1102 electronic discharge summaries for abbreviations and their senses. Three medical doctors assigned a danger level to ambiguous abbreviations based on their potential to cause patient harm if misinterpreted. The predictors for dangerous abbreviations were determined using binary logistic regression. Abbreviations accounted for 19% (33,824) of total words; 22.6% (7640) of those abbreviations were ambiguous; and 52.3% (115) of the ambiguous abbreviations were labelled dangerous. Increased risk of danger occurs when abbreviations have more than two senses (OR = 2.991; 95% CI 1.586, 5.641), they are medication-related (OR = 6.240; 95% CI 2.674, 14.558), they are disorders (OR = 7.771; 95% CI 2.054, 29.409) and procedures (OR = 3.492; 95% CI 1.376, 8.860). Reduced risk of danger occurs when abbreviations are confined to a single discipline (OR = 0.519; 95% CI 0.278, 0.967). Managing abbreviations through awareness and implementing automated abbreviation detection and expansion would improve the quality of clinical documentation, patient safety, and the information extracted for secondary purposes.
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Affiliation(s)
- Ismat Mohd Sulaiman
- Health Informatics Centre, Planning Division, 26691Ministry of Health Malaysia, Malaysia
| | - Awang Bulgiba
- Centre for Epidemiology and Evidence-based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, 37447University of Malaya, Malaysia
| | - Sameem Abdul Kareem
- Department of Artificial Intelligence, Faculty of Computer Science and Information Technology, 37447University of Malaya, Malaysia
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5
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Park EH, Watson HI, Mehendale FV, O'Neil AQ. Evaluating the Impact on Clinical Task Efficiency of a Natural Language Processing Algorithm for Searching Medical Documents: Prospective Crossover Study. JMIR Med Inform 2022; 10:e39616. [DOI: 10.2196/39616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background
Information retrieval (IR) from the free text within electronic health records (EHRs) is time consuming and complex. We hypothesize that natural language processing (NLP)–enhanced search functionality for EHRs can make clinical workflows more efficient and reduce cognitive load for clinicians.
Objective
This study aimed to evaluate the efficacy of 3 levels of search functionality (no search, string search, and NLP-enhanced search) in supporting IR for clinical users from the free text of EHR documents in a simulated clinical environment.
Methods
A clinical environment was simulated by uploading 3 sets of patient notes into an EHR research software application and presenting these alongside 3 corresponding IR tasks. Tasks contained a mixture of multiple-choice and free-text questions. A prospective crossover study design was used, for which 3 groups of evaluators were recruited, which comprised doctors (n=19) and medical students (n=16). Evaluators performed the 3 tasks using each of the search functionalities in an order in accordance with their randomly assigned group. The speed and accuracy of task completion were measured and analyzed, and user perceptions of NLP-enhanced search were reviewed in a feedback survey.
Results
NLP-enhanced search facilitated more accurate task completion than both string search (5.14%; P=.02) and no search (5.13%; P=.08). NLP-enhanced search and string search facilitated similar task speeds, both showing an increase in speed compared to the no search function, by 11.5% (P=.008) and 16.0% (P=.007) respectively. Overall, 93% of evaluators agreed that NLP-enhanced search would make clinical workflows more efficient than string search, with qualitative feedback reporting that NLP-enhanced search reduced cognitive load.
Conclusions
To the best of our knowledge, this study is the largest evaluation to date of different search functionalities for supporting target clinical users in realistic clinical workflows, with a 3-way prospective crossover study design. NLP-enhanced search improved both accuracy and speed of clinical EHR IR tasks compared to browsing clinical notes without search. NLP-enhanced search improved accuracy and reduced the number of searches required for clinical EHR IR tasks compared to direct search term matching.
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6
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Jaber A, Martínez P. Disambiguating Clinical Abbreviations Using a One-Fits-All Classifier Based on Deep Learning Techniques. Methods Inf Med 2022; 61:e28-e34. [PMID: 35104909 PMCID: PMC9246508 DOI: 10.1055/s-0042-1742388] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background
Abbreviations are considered an essential part of the clinical narrative; they are used not only to save time and space but also to hide serious or incurable illnesses. Misreckoning interpretation of the clinical abbreviations could affect different aspects concerning patients themselves or other services like clinical support systems. There is no consensus in the scientific community to create new abbreviations, making it difficult to understand them. Disambiguate clinical abbreviations aim to predict the exact meaning of the abbreviation based on context, a crucial step in understanding clinical notes.
Objectives
Disambiguating clinical abbreviations is an essential task in information extraction from medical texts. Deep contextualized representations models showed promising results in most word sense disambiguation tasks. In this work, we propose a one-fits-all classifier to disambiguate clinical abbreviations with deep contextualized representation from pretrained language models like Bidirectional Encoder Representation from Transformers (BERT).
Methods
A set of experiments with different pretrained clinical BERT models were performed to investigate fine-tuning methods on the disambiguation of clinical abbreviations. One-fits-all classifiers were used to improve disambiguating rare clinical abbreviations.
Results
One-fits-all classifiers with deep contextualized representations from Bioclinical, BlueBERT, and MS_BERT pretrained models improved the accuracy using the University of Minnesota data set. The model achieved 98.99, 98.75, and 99.13%, respectively. All the models outperform the state-of-the-art in the previous work of around 98.39%, with the best accuracy using the MS_BERT model.
Conclusion
Deep contextualized representations via fine-tuning of pretrained language modeling proved its sufficiency on disambiguating clinical abbreviations; it could be robust for rare and unseen abbreviations and has the advantage of avoiding building a separate classifier for each abbreviation. Transfer learning can improve the development of practical abbreviation disambiguation systems.
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Affiliation(s)
- Areej Jaber
- Applied Computing Department, Palestine Technical University - Kadoorie, Tulkarem, Palestine.,Department of Computer Science, Universidad Carlos III de Madrid, Leganés, Spain
| | - Paloma Martínez
- Department of Computer Science, Universidad Carlos III de Madrid, Leganés, Spain
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7
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Khan MNH, Shafiq H, Ilyas MW, Jamshed MH, Qureshi AI, Khan BG, Anjum N. Use of abbreviations in consent forms for orthopaedic surgery: A pilot study. Ann Med Surg (Lond) 2021; 71:102949. [PMID: 34712478 PMCID: PMC8529392 DOI: 10.1016/j.amsu.2021.102949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022] Open
Abstract
Background Consent is a process of communication and the consent form is an important legal document of the evidence of discussion between doctor and patients. We observed frequent use of abbreviations in the consent forms in our department that can result in misunderstanding and miscommunication when consenting patients for orthopaedic procedures. Methods We completed an audit cycle starting by reviewing a total of 350 consent forms retrospectively in level one trauma centres in October–November of 2019 for different orthopaedic trauma procedures. The standards for the project were guidelines published by the general medical council (GMC), The royal college of surgeons (RCS) Glasgow, and the British orthopaedic association (BOA).The results were presented at our mortality and morbidity meeting. Written Feedback was obtained from the attending members on how a change can be implemented to increase ccompliance in filling consent forms. A generic email was sent to all medical professionals to avoid the use of abbreviations on the document and encourage colleagues to point out errors if they spot them. The use of full medical terms and to avoid abbreviations in consent form was well advertised, The re-audit was performed for the period of January & February 2020 that included 400 consent forms. The results were analysed and compared with our original audit results. Results The use of abbreviations declined from 54% in first audit to 22% in the re-audit. DVT and PE were the most common abbreviations. Conclusion This audit cycle has shown the importance of education and reminders to the health professionals in achieving better adherence to the guidelines and improves patient care. Consent is as important as any basic principle on which surgical practice is carried out. There are many different guidelines in place to prevent using abbreviations. Use of simple language is important for good understanding of the procedure especially in consenting. Our study looked at different abbreviations used and how they can be prevented.
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Affiliation(s)
- M Noah H Khan
- Royal Victoria Hospital, Belfast, Flat 3 Blenheim Court 56-58 Westwood Road, Southampton SO17 1ES, UK
| | | | - Muhammad Waqas Ilyas
- MRCS Edinburgh Registrar Trauma and Orthopaedics University Hospital Southampton, NHS Foundation Trust, UK
| | | | | | | | - Neshat Anjum
- Consultant Traua and Orthopedic Surgeon Southampton General Hospital, UK
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8
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Coghlan A, Turner S, Coverdale S. Danger in discharge summaries: Abbreviations create confusion for both author and recipient. Intern Med J 2021; 53:550-558. [PMID: 34636114 DOI: 10.1111/imj.15582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/26/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The transition from hospital inpatient care to medical care in the community is a high-risk period for adverse events. Inadequate communication, including low quality or unavailable discharge summaries, has been shown to impact patient care. AIMS Assess use of abbreviations in clinical handover documents from inpatient hospital teams to general practitioners (GPs), and the interpretation of these abbreviations by GPs and hospital-based junior doctors. METHODS Retrospective audit of 802 discharge summaries completed during a one-week period in 2017 by a Queensland regional health service. GPs and local junior doctors then attempted interpretation of twenty relevant abbreviations. RESULTS 99% (794) discharge summaries included abbreviations. 1612 different abbreviations were used on 16 327 occasions. The median number of abbreviations per discharge summary was 17 (range 0-86). 254 GPs and 62 junior doctors responded to a survey which found that no abbreviation was interpreted the same by all respondents. GPs and junior doctors were unable to offer any interpretation in 17.9% and 15.2% of cases respectively. GPs offered a greater range of interpretations than junior doctors, with a median of 9 and 3 different interpretations per abbreviation respectively. 94% (239) of GPs felt that the use of abbreviations in discharge summaries had the potential to impact patient care. 152 (60%) GPs felt that time spent clarifying abbreviations in discharge summaries could be excessive. CONCLUSIONS Abbreviations are often used in discharge summaries, yet poorly understood. This has the potential to impact patient care in the transition period after hospitalisation This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anna Coghlan
- Sunshine Coast Hospital and Health Service, 6 Doherty St, Birtinya QLD AUS 4575.,Fernlands Radius Medical Centre, 10 Woodhill Road, Ferny Hills QLD AUS 4055.,University of Queensland Faculty of Medicine, Herston QLD AUS 4006, Australia
| | - Sophie Turner
- Sunshine Coast Hospital and Health Service, 6 Doherty St, Birtinya QLD AUS 4575.,Metro North Hospital and Health Service, 7 Butterfield St, Herston QLD AUS 4006, Australia.,University of Queensland Faculty of Medicine, Herston QLD AUS 4006, Australia
| | - Steven Coverdale
- School of Medicine, Sunshine Coast, Griffith University, 6, Doherty St, BIRTINYA, QLD 4575, Australia
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9
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Holper S, Barmanray R, Colman B, Yates CJ, Liew D, Smallwood D. Ambiguous medical abbreviation study: challenges and opportunities. Intern Med J 2020; 50:1073-1078. [DOI: 10.1111/imj.14442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/22/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Sarah Holper
- Department of General Medicine The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Rahul Barmanray
- Department of General Medicine The Royal Melbourne Hospital Melbourne Victoria Australia
- Department of Diabetes and Endocrinology The Royal Melbourne Hospital Melbourne Victoria Australia
- Department of Medicine (Royal Melbourne Hospital) The University of Melbourne Melbourne Victoria Australia
| | - Blake Colman
- Department of General Medicine The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Christopher J. Yates
- Department of General Medicine The Royal Melbourne Hospital Melbourne Victoria Australia
- Department of Medicine (Royal Melbourne Hospital) The University of Melbourne Melbourne Victoria Australia
| | - Danny Liew
- Department of General Medicine The Alfred Hospital Melbourne Victoria Australia
| | - David Smallwood
- Department of General Medicine The Royal Melbourne Hospital Melbourne Victoria Australia
- Department of General Medicine Austin Health Melbourne Victoria Australia
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10
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Soto-Arnáez F, Sebastián-Viana T, Carrasco-Garrido P, Fernández-de-las-Peñas C, Parás-Bravo P, Palacios-Ceña D. Estudio descriptivo del conocimiento de enfermeras y médicos de las abreviaturas en los informes de alta hospitalaria. ENFERMERIA CLINICA 2019; 29:302-307. [DOI: 10.1016/j.enfcli.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/31/2018] [Accepted: 10/17/2018] [Indexed: 11/16/2022]
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11
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Rohr B, Berger A, Cotseones J, Hossler N, Hossler E. Understanding of abbreviations in dermatology: a survey of primary care providers. J Eur Acad Dermatol Venereol 2019; 33:e306-e308. [DOI: 10.1111/jdv.15586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- B.R. Rohr
- Department of Dermatology Geisinger Health System 16 Woodbine Lane Danville PA 17821 USA
| | - A. Berger
- Biostatistics Core Department of Biomedical and Translational Informatics Geisinger Health System 100 North Academy Avenue Danville PA 17822 USA
| | - J. Cotseones
- Department of Dermatology Geisinger Health System 16 Woodbine Lane Danville PA 17821 USA
- Department of Dermatology Northwestern Medicine 636 Raymond Drive Naperville IL 60563 USA
| | | | - E. Hossler
- Department of Dermatology Geisinger Health System 16 Woodbine Lane Danville PA 17821 USA
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Álvarez Alvargonzález N, M Ali Al Shaban Rodriguez OW, García Álvarez G, Azanza Balmori A, Rodríguez Turiel C. [(Ab)use of medical abbreviations, safety and quality of care]. J Healthc Qual Res 2019; 34:46-47. [PMID: 30606651 DOI: 10.1016/j.jhqr.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 08/11/2018] [Accepted: 08/21/2018] [Indexed: 06/09/2023]
Affiliation(s)
| | | | - G García Álvarez
- Psychiatry Service. University Hospital San Agust? N. Avil? S, Asturias, Spain
| | - A Azanza Balmori
- Psychiatry Service. University Hospital San Agust? N. Avil? S, Asturias, Spain
| | - C Rodríguez Turiel
- Psychiatry Service. University Hospital San Agust? N. Avil? S, Asturias, Spain
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13
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Weale J, Soysa R, Yentis SM. Use of acronyms in anaesthetic and associated investigations: appropriate or unnecessary? - the UOAIAAAIAOU Study. Anaesthesia 2018; 73:1531-1534. [DOI: 10.1111/anae.14450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2018] [Indexed: 11/26/2022]
Affiliation(s)
- J. Weale
- Magill Department of Anaesthesia; Chelsea and Westminster Hospital; London UK
| | - R. Soysa
- Magill Department of Anaesthesia; Chelsea and Westminster Hospital; London UK
| | - S. M. Yentis
- Magill Department of Anaesthesia; Chelsea and Westminster Hospital; London UK
- Imperial College London; UK
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Abstract
Proper completion of death certificates is of vital importance. This study assessed the accuracy of death certification at one major hospital in Riyadh, Saudi Arabia. We collected all certificates from 1997 to 2016 and scored them on the degree of accuracy. We found no errors of incompleteness or missed contributors to death. However, in all certificates (100%), cause of death was either incorrect or absent; 75% provided no cause of death. Further large-scale studies should be conducted in other hospitals to determine the exact prevalence of these serious errors.
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Affiliation(s)
- Khaldoon Aljerian
- a Forensic Medicine Unit, Department of Pathology, College of Medicine , King Saud University , Riyadh 12372 , Saudi Arabia
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15
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Hamiel U, Hecht I, Nemet A, Pe'er L, Man V, Hilely A, Achiron A. Frequency, comprehension and attitudes of physicians towards abbreviations in the medical record. Postgrad Med J 2018. [PMID: 29540451 DOI: 10.1136/postgradmedj-2017-135515] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Uri Hamiel
- Department of Pediatrics, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Idan Hecht
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Ophthalmology, Edith Wolfson Medical Center, Holon, Israel
| | - Achia Nemet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Ophthalmology, Edith Wolfson Medical Center, Holon, Israel
| | - Liron Pe'er
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Ophthalmology, Edith Wolfson Medical Center, Holon, Israel
| | - Vitaly Man
- Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University, Beer Sheva, Israel
| | - Assaf Hilely
- Department of Ophthalmology, Kaplan Medical Center, Rehovot and the Hebrew University of Jerusalem-Hadassah Medical School, Jerusalem, Israel
| | - Asaf Achiron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Ophthalmology, Edith Wolfson Medical Center, Holon, Israel
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Shilo L, Shilo G. Analysis of abbreviations used by residents in admission notes and discharge summaries. QJM 2018; 111:179-183. [PMID: 29237038 DOI: 10.1093/qjmed/hcx241] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There are abbreviations that are used daily such as BP for blood pressure and ECG for electrocardiogram, but many of the abbreviations found in medical documents are unclear. AIM The purpose of this study was to assess the frequency, type and comprehension of abbreviations in admission notes and discharge letters composed by orthopedic surgery and medical residents. METHODS Abbreviations were extracted from discharge letters and admission notes composed by residents from orthopedic surgery and medical wards. The frequency of use of the abbreviations was determined. Additionally, the fifty commonest abbreviations from each specialty were graded by three medical and three orthopedic surgery senior physicians as 1. understandable or 2. Ambiguous or unknown. RESULTS The number of abbreviations found in the documents composed by medical and orthopedic surgery residents was 1525 with 80 different abbreviations and 493 with 51 different abbreviations respectively (9.3% and 4.9% of the total word number respectively). Analysis revealed that 14% of the abbreviations from medical ward documents were graded as ambiguous or unknown by medical senior physicians compared with 25% by senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups, senior orthopedic surgeons graded 8% as ambiguous or unknown compared with 21% by the medical senior physicians. CONCLUSION In order to prevent impairment of patient care, only standard abbreviations should be used in medical documents. Measures should be taken to decrease the use of non standard abbreviations such as the incorporation of authorized abbreviations to the electronic medical record.
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Affiliation(s)
- L Shilo
- Clinical Pharmacology Service and Department of Medicine 'C,' Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Shilo
- Beit Berl Academic College, Kfar Saba, Israel
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Abstract
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.
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Affiliation(s)
| | - Simon Bariol
- Department of Urology, Westmead Hospital, Australia
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18
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Chohda E, Doddi S, Sundaramoorthy S, Manton RN, Ahad A, Sinha A, Khawaja H. An audit of consenting practices in a district general hospital. Can we improve? G Chir 2016; 36:263-6. [PMID: 26888702 DOI: 10.11138/gchir/2015.36.6.263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Informed consent, as the declaration of patients' will, forms the basis of legality of medical procedures. A standard form based on the Department of Health model is widely used in the National Health Service (NHS). The aim of this audit process was to assess the current consent practice in comparison to the UK's General Medical Council guidance and local policy and make any appropriate improvements. PATIENTS AND METHODS 254 adult consent forms were reviewed during the patients' admission. Data collected included legible documentation, grade of health professional completing the consent form, providing additional written information, use of abbreviations, securing the consent form in the medical records and, providing a copy to the patient. After initial assessment, interventions in an attempt to improve adherence to guidelines were introduced. A repeat audit of a further set of 110 notes was completed to assess the effectiveness of our interventions. RESULTS Our baseline assessment of 254 consent forms comprised of 198 (78%) elective and 56 (22%) emergency procedures. 87 (34%) consent forms were secure in the medical records. Grade of health professional was recorded in 211 (83%). 191 (75%) forms were legible. 48 (19%) patients were given copy of the consent. Only 24 (9%) patients were given additional written information. Abbreviations were used in 68 (27%) forms. Only 12 (5%) of consent forms met all criteria simultaneously. Re-audit after intervention assessed 110 consent forms; 30 (27%) for elective and 80 (72%) for emergency procedures. 52 (47%) of consent forms were secure in medical records, grade of health professional was recorded in 94 (85%), 101 (75%) forms were legible, 42 (38%) patients received copy of consent and 41 (37%) of patients received additional written information. CONCLUSION Initially only 5% of consent forms completely met GMC guidelines. This demonstrates an alarmingly poor adherence to such guidance that plays a vital role in patient safety, patient ethics autonomy, not to mention potential medico-legal and clinical governance implications for surgical practice. Our intervention has improved the quality of consenting within our hospital according to these guidelines. With these interventions set to continue and further develop, we expect that the quality of the consenting process will continue to provide patients with all that it is designed to.
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Awan S, Abid S, Tariq M, Zubairi ABS, Kamal A, Arshad S, Masood Q, Kashif W, Hamid S. Use of medical abbreviations and acronyms: knowledge among medical students and postgraduates. Postgrad Med J 2016; 92:721-725. [PMID: 27281817 DOI: 10.1136/postgradmedj-2016-134086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Inappropriate use of abbreviations and acronyms in healthcare has become an international patient safety issue. The aim of this study was to assess the knowledge of medical abbreviations and acronyms among residents of the department of medicine at a tertiary-care hospital. METHODS Internal medicine residents (IMRs), subspecialty residents (SRs) and students were asked to complete a self-administered questionnaire which comprised standard abbreviations used in medicine and its various subspecialties. Scores obtained by the residents were classified into three categories: >70% correct answers; 50-69% correct answers; <50% correct answers. RESULTS A total of 77 IMRs, SRs and medical students participated. Overall, good responses were achieved by 53 (68.8%), 16 (20.8%) attained satisfactory responses, and eight (10.4%) had unsatisfactory scores. The majority of SRs achieved good responses (19/22 (86%)), followed by IMRs (30/40 (75%)) and students (4/15 (26.7%)). Evaluation of their knowledge taken from the list of 'do not use' abbreviations showed that 89.6% reported using 'Q.D.' instead of 'once a day', and 93% used 'IU' instead of the entire phrase 'international unit'. The top five 'not to use' abbreviations were ZnSO4, µg, MgSO4, IU and SC, with the frequency 100%, 96%, 94.8%, 93% and 90%, respectively. CONCLUSIONS This study showed that there is a knowledge gap among trainees in medicine regarding the meaning and usage of common medical abbreviations. We therefore recommend proper education of trainees in medicine to ensure they understand the meaning of abbreviations and are aware of the list of 'do not use' abbreviations.
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Affiliation(s)
- Safia Awan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Shahab Abid
- Section of Gastroenterology, Aga Khan University, Karachi, Pakistan
| | - Muhammad Tariq
- Section of Internal Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Ayeesha Kamal
- Section of Neurology, Aga Khan University, Karachi, Pakistan
| | - Sadia Arshad
- Section of Cardiology, Aga Khan University, Karachi, Pakistan
| | - Qamar Masood
- Section of Diabetes and Endocrinology, Aga Khan University, Karachi, Pakistan
| | - Waqar Kashif
- Section of Nephrology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Saeed Hamid
- Section of Gastroenterology, Aga Khan University, Karachi, Pakistan
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Politis J, Lau S, Yeoh J, Brand C, Russell D, Liew D. Overview of shorthand medical glossary (OMG) study. Intern Med J 2016; 45:423-7. [PMID: 25827509 DOI: 10.1111/imj.12668] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 12/10/2014] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- J Politis
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Chemali M, Hibbert EJ, Sheen A. General practitioner understanding of abbreviations used in hospital discharge letters. Med J Aust 2015. [DOI: 10.5694/mja15.00224] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Emily J Hibbert
- Nepean Hospital, Sydney, NSW
- Sydney Medical School — Nepean, Sydney, NSW
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Consenting operative orthopaedic trauma patients: challenges and solutions. ISRN SURGERY 2014; 2014:354239. [PMID: 24653843 PMCID: PMC3933397 DOI: 10.1155/2014/354239] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 12/26/2013] [Indexed: 11/18/2022]
Abstract
Guidelines exist to obtain informed consent before any operative procedure. We completed an audit cycle starting with retrospective review of 50 orthopaedic trauma procedures (Phase 1 over three months to determine the quality of consenting documentation). The results were conveyed and adequate training of the staff was arranged according to guidelines from BOA, DoH, and GMC. Compliance in filling consent forms was then prospectively assessed on 50 consecutive trauma surgeries over further three months (Phase 2). Use of abbreviations was significantly reduced (P = 0.03) in Phase 2 (none) compared to 10 (20%) in Phase 1 with odds ratio of 0.04. Initially, allocation of patient's copy was dispensed in three (6% in Phase 1) cases compared to 100% in Phase 2, when appropriate. Senior doctors (registrars or consultant) filled most consent forms. However, 7 (14%) consent forms in Phase 1 and eleven (22%) in Phase 2 were signed by Core Surgical Trainees year 2, which reflects the difference in seniority amongst junior doctors. The requirement for blood transfusion was addressed in 40% of cases where relevant and 100% cases in Phase 2. Consenting patients for trauma surgery improved in Phase 2. Regular audit is essential to maintain expected national standards.
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