In a bid to eliminate medical errors caused by misuse and misinterpretation of directions on drug prescription and another medical document, the Joint Commission in 2004, established a safety standard on the use of abbreviations, acrtiononyms, and symbols (Joint Commission). This safety standard was officially adopted in 2010 when it was made an element of performance in Information Management Standards (Joint Commission). However, these standards do not apply to health information technology systems (Joint Commission).
The Joint Commission website lists several abbreviations that should not be used. Errors in medical documentation, as most evidence shows, primarily arise due to poor handwriting of the medical practitioner prescribing the drug or entering medical details. The abbreviations, symbols, and acronyms listed as prone to misinterpretation and officially disallowed are outlined below:
The symbol “U” , it is stated, has the potential to cause mixed interpretation the reason being that it can be read as zero (“0”), number four (4), or cc (relates to capacity). This misinterpretation may arise when it is handwritten. It is recommended that full words be used for example “Unit”.
IU, the common abbreviation for International Unit is not allowed. Instead full-length word, “international Unit” should be used. IU may be confused for IV to mean intravenous or number ten (“10”) when poorly handwritten.
The safety standard also prohibits using medical abbreviations such Q.D., Qd, q.d., qd (daily), Q.O.D., QOD, q.o.d, qod (every other day). The Similar letter arrangement and pattern in these abbreviations may easily confuse the user. In addition, the punctuations used may look very different in case it is handwritten without much consideration. To avoid such errors, it recommended the words “daily” and/or “every other day” be used.
Trailing zero, for example in X.0 mg has been dropped in favor of just an integer. The reason cited is that the decimal point may be missed. However, trailing zero is allowed in cases where precision is crucial such as in laboratory tests documentation (Joint Commission).
In a similar fashion omitting leading zero (for example. X mg) in medical documentation is no longer allowed. It is required that the zero be included (0. X mg).
The abbreviation “MS” should never be used. According to the Joint Commission, this short form can be understood to mean morphine sulfate or magnesium sulfate. To avoid this ambiguity full chemical names should be used, that is, “morphine sulfate” or “magnesium sulfate”. It further states that MSO4 and MgSO4 should not be used because they may be “confused for one another” (Joint Commission).
Apart from all the above the Joint Commission has listed other error-prone abbreviations, symbols and acronyms for future reviews and possible prohibition. This is the subject of the next paragraph.
The use of greater than and less than (< and >) can result in errors of reading them as “7” or “L” or simply confused for one another (joint commission). For such symbols, written words are preferred. Abbreviations for drug names can also create confusion as they may be shared by different drugs. The solution proposed is the use of full drug names (Joint Commission). Apothecary symbols may also be unfamiliar to many practitioners and therefore only known metric units should be used. Others listed for future ban are @, µg and cc.
Medical documentation certainly should be clear and free from any possible ambiguity, misinterpretation or confusion. Such shortcomings have dire consequences as far as their usage is concerned. Because many of these errors are caused by variations in our handwriting, it is best to employ electronic devices for this purpose. Computers may offer better clarity.
Reference
Joint Commission. (2010). Facts about the official “do not use “list. Web.