Abstract
Introduction. The dangerous abbreviations not allowed used in the record of the Clinical History, due to an erroneous interpretation, could trigger associated adverse events in health care. Methods. Cross-sectional descriptive study, 15 786 cases registered in the Medical Records of Hospital General del Sur de Quito of 42 clinical and surgical units were reviewed, the use of dangerous abbreviations was included, the acronyms allowed according to the regulations of the Ministry of Public Health of Ecuador were excluded. The information was consolidated in a database in Excel 2017 format and the compliance and frequencies of abbreviations used with the SPSS Version 22.0 program were analyzed. Results. 69,84% (n=11 026 services) complied with the proper use of allowed abbreviations, the clinical area with 74,9% and the surgical area with 62,62%. 6 199 dangerous abbreviations were found, the most frequent being “(…) FR, FC, LPM, RPM, TA, TAM, RX, GSRN, CD4, M2, CD8, ASC, ECG, AQX, NPO, VIH, BH, FUM, HTA, RHB, SAT, GSM, TAC, RHA, DH, RP, APP, AM, TTO, IDG (…)”. Conclusions. Percentages of higher compliance were determined in the clinical units, followed by the surgical ones. The abbreviations used in the records of the Clinical Histories are not included in Ministerial Agreement 00000115, Patient Safety Manual - User, of the Ministry of Public Health of Ecuador.
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