Campaign to Eliminate Use of Error-Prone Abbreviations

Abstract

The FDA and the Institute for Safe Medication Practices (ISMP) announced a new campaign focused on the elimination of the use of error-prone abbreviations in medicine. It has long been recognized that the use of abbreviations in prescriptions and drug orders has been a root cause of a number of medication errors. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) has even specified that certain abbreviations must appear on an accredited organization’s do-not-use list since this type of error is easily preventable by avoiding the use of those abbreviations for drug names, dosage forms, dosage units, and within the SIG of a medication order. Despite this knowledge and previous efforts, medication errors still occur because the use of errorprone abbreviations in medical communications has not been eliminated. The new campaign includes a national education effort to eliminate the use of ambiguous medical abbreviations that are frequently misinterpreted and can lead to mistakes that result in patient harm. The target audience for the campaign is everyone involved with medical communication, including written medication orders, computer-generated labels, medication administration records, pharmacy or prescriber computer order entry screens, and commercial medication labeling, packaging, and advertising. These groups will include health care professionals, health care students, medical writers, the pharmaceutical industry, and FDA staff. The message will be delivered with targeted educational materials, articles for professional journals, and presentations at various conferences and meetings. By broadening the scope of this type of campaign, we can only hope that its impact will be greater than previous efforts targeted at only health care professionals. Components of this campaign include a brochure to be distributed to medical professionals, the pharmaceutical industry, and medical publishing professionals; a print public service ad that will be sent to professional trade publications; posters with reminders about commonly used error-prone abbreviations for health care facilities; an online tool kit of materials, including PowerPoint slides for presentations at conferences and meetings; and a patient safety video. All of these components can be accessed at www.fda.gov/cder/ drug/MedErrors and www.ismp. org/tools/abbreviations. Another useful tool is the list of error-prone abbreviations, symbols, and dose designations developed by ISMP. This list is easily accessible on the ISMP Web site (www.ismp.org) and makes a great reference piece near work stations and office computers. The success of this program in reducing medication errors is dependent on practitioner acceptance and implementation of these recommendations. We all need to do our part to ensure that this is a successful program, so we can decrease the risk of avoidable error from causing harm to our patients. So the next time you see one of these abbreviations, let the person that used it know about the problem and share some of these wonderful resources (brochure, posters, or Web sites) with them. You may also want to consider adding a section on or reference to this topic to your educational presentations (eg, inservices, continuing education, public forums). Each of these is an important step in decreasing the risk of a medication error and should be implemented whenever possible.