Drug Topics - October 15, 2007 - (Page 6)

6 DRUG TOPICS OCTOBER 15, 2007 www.drugtopics.com Of Interest to Pharmacists /c d ug K 1 Eight tips for vanquishing drug errors from abbreviations Michael Barbella asey Thompson, Pharm.D., knows what can happen when healthcare professionals use abbreviations. But he also knows how difficult it can be to break the habit. “It really is ingrained in the culture of health care,” said Thompson, director of patient safety at ASHP. “When you have something embedded in our educational system, it takes a very long time to rid the system of what we know. For me, it’s a bit problematic. We have to continue to state the obvious—abbreviations have always caused patient harm, abbreviations still cause patient harm, and abbreviations will continue to cause patient harm.” A new study reveals just how much patient harm is caused by abbreviations: 5% of 30,000 medication errors reported to the national MEDMARX database between 2004 and 2006 involved shorthand. Abbreviations, according to the report, lead to 7,000 deaths annually. Abbreviation errors originated most often from medical staff (78.5%), though nurses and pharmacists also made shorthand mistakes, according to the eight-page study The Impact of Abbreviations on Patient Safety. The top shorthand mistakes among pharmacists include BID, µg, and d/c. The three most common types of errors caused by the use of abbreviations were prescribing, improper dose/quantity, and incorrectly prepared medication, the study states. Mistakes in dispensing medication accounted for 2.9% of all errors. “D/C—I’m not sure whether that means discontinue or discharge,” said Rodney Hicks, Ph.D., A.R.N.P., manager of patient safety research at United States Pharmacopeia in Rockville, Md., and one of three authors of the study. “The danger comes when it’s taken out of context.” Hicks and his coauthors recommend that healthcare professionals spell out the names of drugs and accompanying instructions. “We have to train our providers to spell things out. It’s very easy, and we’re talking milliseconds in time,” he noted. “The time argument can easily be deflated. That’s the No. 1 pushback I hear— ‘I have to [abbreviate] because it saves time.’ Doing things faster is not always better for the patient.” In the box below are eight ways Hicks and his colleagues recommend minimizing abbreviations. DT Recommendations for minimizing abbreviations Initiate a campaign to eradicate the use of abbreviations in clinical practice; an interdisciplinary approach is essential. Use “Dear Doctor” letters. Post lists of prohibited abbreviations on hospital identification badges, in patient charts, newsletters, on Intranet sites, on computer screensavers, and on announcement boards. Use peer-initiated accountability. Give rewards for nonusage of abbreviations. 2 3 Educate staff on the harmful effects of abbreviations. Minimize the use of abbreviations; write out the drug name, schedule, and unit of measure. Prohibit use of abbreviations in patient charts, preprinted order forms, and computer programs. 4 5 6 7 8 Clarify intent to avoid misinterpretation if abbreviations are found. Introduce computerized physician order entry (CPOE) in a manner that minimizes the use of abbreviations. Review all computer-entry software for potential abbreviation issues. Prohibit the use of abbreviations in all facility publications (e.g., newsletters). Include industry, organizational, educational, and professional bodies in error-prone abbreviation awareness and avoidance. Source: The Impact of Abbreviations on Patient Safety. Luigi Brunetti, Pharm.D.; John P. Santell, M.S., R.Ph.; Rodney W. Hicks, Ph.D., A.R.N.P. http://www.drugtopics.com

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Drug Topics - October 15, 2007 Contents Drugs in the Pipeline for Diabetes Vanquishing Med Errors from Abbreviations What Pharmacy Schools Never Taught You The Week at a Glance What Kinds of Mistakes Do Pharmacists Make?

Drug Topics - October 15, 2007

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