The "Do Not Use" List from ISMP and Joint Commission

“How Can Eliminating Abbreviations Reduce Errors”

     One important reason why some medical abbreviations are dangerous is that health care has a long history of being a confusing, exhausting, anxiety producing profession.  Health workers who have the risk of injuring or killing their patients and are known to be victims of multiple distractions, rigid time constraints and the center and focus of blame.  (1) (2) (3) (8)

     In an ideal world, all caregivers would have time to research their patients’ medications, memorize proper dosages, and to call the doctor for clarification.  (1) In thousands of places all over the country, there are nurses with anywhere from twenty-five to fifty patients or more.  In true-to-life case scenarios, they might be passing meds with a migraine and they are expected to survive this and to medicate them with no errors.  If their co-worker calls in sick, they might be forced to work a double shift and can legally be made to work for twenty hours strait.  (1)  As if this was not already enough, the use of confusing medical abbreviations has proven to leave patients in an unsafe situation and nurses with a high amount of liability.

     “One of the most widely publicized sentinel events involved the death of a 9-month old infant who received 10 times her weight-appropriate dose of morphine due to what is now commonly referred to as the "naked decimal point" (5)  

     “In this case .5 milligrams was misinterpreted in transcription as 5 milligrams.  A nurse who was unfamiliar with pediatric dosing administered the morphine.”  “Sadly, a similar error was identified as one of the first openly reported medication safety errors 30 years earlier.”  (9)

     The improper use of “.5 mg.” instead of “0.5 mg.” for safety, is the second item under “Dose designations and other information,” on ISMPs “List of Error-Prone Abbreviations.”  It was listed here specifically on account of cases like the above-mentioned infant death. 

      

     In an ideal situation, the baby in the above-quoted report would never have died because the med-nurse would have researched the drug before giving it, either/or, had the dosage for infants memorized by heart.  Because most med nurses are overwhelmed with their workload and do not always remember the right dosages, all orders like this one need to have a zero before the decimal as is suggested by JCAHO AND ISMP. 

 “Should Written Policies Be Developed for Abbreviation Usage?”  “What Should the Policies Contain?”

    “Despite repeated warnings for more than 25 years by the Institute for Safe Medication Practices (ISMP)--and other organizations--about the dangers associated with using certain abbreviations when communicating medication information, the practice of using these dangerous abbreviations continues, increasing the potential for patient harm.”  (6)

     The lists provided by ISMP and JCAHO are made according to a history of errors reported to them.  As far as, “what the policies should contain,” these two entities (JCAHO and ISMP) had the right idea when they made a list of proven dangerous abbreviations and made them complete with the reasons why practitioners should not use them and what terms to use instead.   (5) (6) (7)

“When Are Abbreviations Acceptable?  Who Should Use Them and Why?”

     Let’s suppose you are not a prescribing doctor or pharmacist who deals in life-threatening situations.  Let’s suppose that you are not transcribing medical orders.

    If an agency-aide has a new patient and the care-plan reads, “Shower Q.D.”  This has almost no chance of resulting in any deathly error.  Even if it is mistaken for, “q.i.d. (four times daily) or q.o.d. (every other day) then some communication and common sense are all that is needed to resolve this. 

      Furthermore, if a group of staff-members use the same abbreviations in their patient-care charts every week, i.e. “T.D.” for “totally dependent or “S” for self-sufficient, this has no chance for bringing about life-threatening medical errors.  Everyone on the staff knows what their facility abbreviations mean.  When they chart the record of care given to their patients, they use the abbreviations to indicate past occurrences, not to give orders.  Therefore, the abbreviations they use are not dangerous.   

 “According to Information in Online Articles do you think enough steps have been taken to reduce errors?”

     In my web-research, I came across a heated debate among practitioners about the “Do Not Use” list.  Post #19 reads as follows. 

     “To all the posters here, if you lost a loved one due to some doctor’s sloppy writing, a pharmacist not understanding the writing and not being able to contact the doctor to get actual wording (because they are too busy) or a nurse not understanding it and charting it incorrectly, etc., you would think differently about it.  You are just used to having your way, you don’t want to change, and it hasn’t affected you yet.”  (4)

     The problem exposed in the above quoted post is that not all practitioners respect or agree with the guidelines written for them by ISMP and JCAHO.  

     As indicated in their discussion, a number of health practitioners take offense to the guidelines provided for them and some individuals have chosen to ignore them.  Their web-forum only had a small number of posters who show concern that veering away from the advice given on the “Do Not Use” lists might cause more patient-deaths.  

    

    Post #7 in the aforementioned “white coats call room” thread describes another ongoing problem.  “Sometimes the sender has to be considerate of the fact the receiver is not actually bright.”  

    The words, “not actually bright,” are not an attack on any caregiver’s mentality.  The instead refer to a multitude of problems.  These problems include nurses whose obligations have them working at a frantic pace with many distractions (1) (2) (3) (8) and who do not have time to research the meds they give. (1) They also refer to problems discussed by ISMP and JCAHO of the doctors’ bad handwriting.  

     Just because the dangerous abbreviation lists are based on years of research does not mean more abbreviations (not yet on these lists) won’t be the cause of medical errors.     

     As long as there are practitioners who refuse to type their orders and use confusing abbreviations, there is not enough being done to protect patients.