Dangerous and Unapproved Abbreviations at A Joint Commission International Accredited Hospital in Saudi Arabia

Background: Abbreviations which resulted in harmful patient errors or death are termed dangerous abbreviations. These abbreviations were included in The Joint Commission “Do Not Use” list of abbreviations launched in May 2005. Objectives: The aim of the present study is to assess physicians’ and nurses’ use of unapproved and dangerous abbreviations and to explore physicians’ and nurses’ opinion regarding the use of these abbreviations. Methods: The study was conducted in a Joint Commission International (JCI) accredited hospital in Eastern Saudi Arabia. Two study designs were used: retrospective descriptive and cross-sectional descriptive. Data were collected through reviewing 384 paper records and distributing a questionnaire to a random sample of 58 physicians and nurses. Results: The study revealed that the average number of dangerous abbreviations per record was 2.2 while the average number of unapproved abbreviations per record was 1.96. The most frequent dangerous abbreviation reported in the present study was Discharge/Discontinue D/C accounting for 73% of the total identified dangerous abbreviations for both physicians and nurses. The ability of physicians and nurses to correctly identify the meaning of the most commonly used dangerous abbreviation and unapproved abbreviation ranged between 37.9% and 69.0%. Conclusions: The study revealed high use of dangerous and unapproved abbreviations at the study hospital. Few dangerous abbreviations constitute the majority of identified abbreviations. A quality improvement intervention needs to be instituted to reduce abbreviation use at the study hospital. INTRODUCTION ''Abbreviations" are shortening a word or phrase to a form representing an entire word or phrase while acronyms are derived by grouping letters from several terms. Symbol is something such as an object, picture, written word, a sound, or particular mark that represents something else by association, resemblance, or convention.(1) In medicine, abbreviations are a convenience, a time saver, a space saver, and a way of avoiding the possibility of misspelling words. Abbreviations are so ingrained that health care professionals use them in notes to themselves, casual 952 Bull High Inst Public Health Vol.37 No.4 [2007] correspondence, and personal to-do lists. Despite their benefits, abbreviations are sometimes not understood or misread or are interpreted incorrectly. Moreover, their use lengthens the time needed to train individuals in the health fields, wastes the time of healthcare workers in tracking down their meaning, at times delays the patient’s care and occasionally results in patient harm.(2-4) The Joint Commission (TJC) standards require hospitals to standardize abbreviations, acronyms, and symbols that will be used to guide documentation. Organizations create their own standard abbreviations list by performing a careful review of the literature, their own experiences and develop standard abbreviations list with the involvement of physicians. Creating lists of standardized abbreviations, acronyms, and symbols is only the first step. The next step is to ensure that staff complies with the list.(5) Dangerous abbreviations are also known as "error-prone abbreviations" or “unsafe abbreviations”. They are referred to as "dangerous" because they can be misinterpreted and involved in harmful patient errors or death. Dangerous abbreviations use can lead to errors in medication administration including incorrect dose, incorrect frequency, incorrect route, or even the incorrect drug being given.(6-7) In an effort to avoid potential errors of these abbreviations, TJC affirmed its “Do Not Use” list of abbreviations in May 2005 as part of the requirements for meeting National Patient Safety Goal (NPSG) 2B which states that “organizations standardize a list of abbreviations, acronyms, and symbols not to be used throughout the organization”. The goal requires organizations to achieve 90% compliance for handwritten documentation.(5,8-10) Surveys conducted during the first six months of 2005 show that this goal has the highest level of noncompliance among all the National


INTRODUCTION
''Abbreviations" are shortening a word or phrase to a form representing an entire word or phrase while acronyms are derived by grouping letters from several terms.
Symbol is something such as an object, picture, written word, a sound, or particular mark that represents something else by association, resemblance, or convention . (1) medicine, abbreviations are a convenience, a time saver, a space saver, and a way of avoiding the possibility of misspelling words.Abbreviations are so ingrained that health care professionals use them in notes to themselves, casual Bull High Inst Public Health Vol.37 No. 4 [2007]   correspondence, and personal to-do lists.
Despite their benefits, abbreviations are sometimes not understood or misread or are interpreted incorrectly.) The Joint Commission (TJC) standards require hospitals to standardize abbreviations, acronyms, and symbols that will be used to guide documentation.
Organizations create their own standard abbreviations list by performing a careful review of the literature, their own experiences and develop standard abbreviations list with the involvement of physicians.Creating lists of standardized abbreviations, acronyms, and symbols is only the first step.The next step is to ensure that staff complies with the list. (5) In an effort to avoid potential errors of these abbreviations, TJC affirmed its "Do Not Use" list of abbreviations in May 2005 as part of the requirements for meeting National Patient Safety Goal (NPSG) 2B which states that "organizations standardize a list of abbreviations, acronyms, and symbols not to be used throughout the organization " .
(10)  Patient Safety Goal NPSG requirements. (5)e Joint Commission "Do Not Use" list represents a minimum requirement and additional items are presented by TJC (10) and other organizations such as The Institute for Safe Medication Practices (ISMP) (11)  annually.(2) The list is available online through the hospital intranet.Identified abbreviations were compared to the approved hospital abbreviation list and "Don't use list" published by the TJC and Identified abbreviations not found in the approved abbreviation list were categorized into two categories as follows: 1. Dangerous abbreviation: included in TJC official or additional "Do Not Use" lists and error-prone abbreviations of the Institute for Safe Medication Practices (ISMP) (10)(11) 2. Unapproved abbreviation: abbreviation not included in the hospital abbreviation list.
A number of abbreviations were written     1) which increase patients' risks as these notes are directly related to medications. (5,12)entified abbreviations belonging to the Joint Commission "Do Not Use list" amounted to 89 abbreviations (Table 2), of these 76 were found in clinician's orders and progress notes.The Joint Commission (TJC) standard of 90% compliance with "Do Not Use list" for all orders and all medication-related documents (5) was not met at the study hospital (only 29% of records. The most frequent dangerous abbreviation reported in the present study was D/C accounting for 73% of the total identified dangerous abbreviations for both physicians and nurses (Table 2).D/C is considered dangerous abbreviations because patient's medications have been Nour El-Din MM 957 prematurely discontinued when "D/C" was intended to mean "discharge" versus "discontinue". (11)Although D/C is not included in the minimum Joint Commission "Do Not Use list", it has been included in the Institute of Safe Medication Practices list (11) and was recommended as an additional dangerous abbreviation in literature. (13,14)Moreover, D/C has been identified as one of the "Top Ten" most problematic drug or dose abbreviations in a survey conducted at Naval Hospital Naples. (15)The correct interpretation of the first day of joining departments.This results in familiarity of physicians and nurses with both approved abbreviation and "Do Not Use" lists (Table 4).However, familiarity was not associated with high compliance, which points to the importance of motivational and controlling mechanisms to enhance compliance with abbreviation standards.)(18)(19) Of these, a study reported significant reduction in the use of dangerous abbreviations following a two step intervention which were education followed by a protocol not to dispense drugs in orders containing dangerous abbreviations. (19)mitations of the study include small abbreviations (Cc, Trailing zero, Drug name and dose run together, Qhs) accounted for approximately 85% (716 out abbreviations should be the focus of the intervention.CONCLUSIONThe present study revealed high use of dangerous and unapproved abbreviations by physicians and nurses at the study hospital.Few dangerous abbreviations constitute the majority of identified abbreviations.High percentage of surveyed physicians and nurses were unaware about the correct meaning of the most frequent dangerous and unapproved abbreviations.A quality improvement intervention that utilizes creative methods, in addition to education, needs to be instituted to reduce abbreviation use at the study hospital.

Table 2 : Distribution of dangerous abbreviations according to healthcare provider
* On the official Joint commission (TJC) "Do Not Use" list