Monday, March 26, 2007

Forbidden Pleasures

I lied. This is really about forbidden abbreviations. But I will do anything for more readers. (No, not really anything....)

One safety improvement I have learned about during the past several of years was the effort to prohibit certain medical abbreviations. This is a Joint Commission requirement, and it is a really, really good one.

For those of you non-medical folks out there, let me provide some examples relating to medication dosages. Now, you have to imagine these things being written in a doctor's handwriting to get the whole point. (Admittedly, this is corrected with computerized order entry, but that still does not exist everywhere.)

Trailing zeros. If you write a dosage that is supposed to be in whole units like this -- 1.0 mg -- it will often be read as "10 mg". That is a big difference, an entire order of magnitude. So the rule is "don't use terminal zeros for doses expressed in whole units." So it is properly done like this -- 1 mg.

Missing leading zeros. In contrast, when a dosage is a fractional amount, it is unacceptable to leave off the zero, like this -- .5 mg -- because it is easy for the decimal not to be seen and the dosage read as "5 mg", another order of magnitude problem. So the rule is to always use a preceding zero when the dose is less than a whole unit -- 0.5 mg.

You have to use some imagination for these next two, but remember, some people have really bad handwriting! An international unit was often called an IU. With bad handwriting, this could be read as "IV" (intravenous) or "10" (ten). The solution: Write out "international unit." Ditto for unit, or U, which could be mistaken for 0 (zero); 4 (four); or cc (cubic centimeter). So, it is now written out as "unit".

For frequency of medication, the old QOD, every other day, is gone. The "O" can be confused with a period, as in Q.D (once per day). What's the new terminology? -- "every other day."

When these requirements were first introduced, there was substantial resistance from some in the profession. That is pretty much past now, as people have become retrained, but there is occasional backsliding. I hope the medical schools are teaching the new rules so we don't have to retrain all those interns!

6 comments:

Anonymous said...

With the advent of our EMR we are finding this a less and less issue.
When the program will not allow inappropriate abbreviations, it makes us enter it correctly /safely.
This is not to say there are not a lot of OTHER headaches with EMR...
Just gotta remember to take the good with the bad and eventually it will get better!
LJ
Vancouver,WA

Labor Nurse said...

I can speak for the nursing schools in that they have incorporated the "bad" abbreviations and medication documentation safety into their curriculum. I certainly think that this contributes to seeing less of the old school style of abbreviations. I also can not remember the last time I saw anyone write the forbidden abbreviations.

RJS said...

"When these requirements were first introduced, there was substantial resistance from some in the profession. That is pretty much past now, as people have become retrained, but there is occasional backsliding. I hope the medical schools are teaching the new rules so we don't have to retrain all those interns!"

Well they're learning it somewhere because we rarely see it out in The Real World. (That is, the non-institutional environment).

QOD is still pretty common. Well, as common as QOD dosing is... which isn't very common at all. ;)

And it's generally pretty obvious when it's QOD -- only the most inexperienced technicians miss it. In retail, anyway. Mistaking an "O" for a period is pretty hard. More likely the pharmacy person's eyes are going to slide over the "O" out of habit, not because they couldn't read it.

Domenico Savatta, M.D. said...

One of the things I found most annoying to learn in medical school was the physician abbreviations.

I often thought they were unclear. I think we should do away with all abbreviations.

I think you hit on the big thing, electronic medical records are the way to help eliminate even more errors.

lisa said...

How interesting to read this...growing up as the granddaughter of a Bronx pharmacist, we often heard the tale of how my grandfather saved a kid's life by catching exactly the type of "order of magnitude" error that you mention...the physician had apparently ordered a dose for a child that would have incapacitated an elephant.

Ari F. said...

I've always found it amazing that standards organizations can recommend replacing a two-letter abbreviation with a 12-letter two-word monster (e.g. "IU" vs. "international unit") with a straight face. I understand the impulse to mandate things in the name of patient safety, but how many more lives would have been saved if they had made "I.Unit" acceptable instead. Mandates are all well and good, but even if you have all the power in the world your goals will still be reached faster by taking into account the incentives of person receiving the mandate. Faster is better for physicians.

--Ari Friedman