Abbreviations and Acronyms in Healthcare: When Shorter Isn’t Sweeter
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Abbreviations and Acronyms in Healthcare: When Shorter Isn’t Sweeter
Ivy Fenton Kuhn, MSN, CRNP, CNORPediatr Nurs. 2007;33(5):392-398. ©2007 Jannetti Publications, Inc.
Abstract and Introduction
The use of abbreviations and acronyms in healthcare has become an international patient safety issue. Common problems include ambiguous, unfamiliar, and look-alike abbreviations and acronyms leading to misinterpretation and medical errors. The Joint Commission mandated the implementation of its “do not use” list in 2004 prohibiting the use of a minimum number of abbreviations. The Institute for Safe Medication Practices (ISMP) has been a champion in the drive to warn both the healthcare community and the public. The problem continues as institutions attempt to comply and ensure patient safety by various strategies including education, enforcement, and leadership. The scope of the problem is far greater than the list provides for; the solutions have not been elucidated by the literature and implementation challenges have yet to be conquered. Recommendations for best practice and implementation are included.
This anecdote dramatically illustrates one form of the misuse of abbreviation in the healthcare community. This incident happened over 15 years ago. Our focus at the time was to correct the misinterpretation of CP for this child moving forward. The larger picture of the dangers of abbreviations and acronyms in healthcare eluded us then. In the decades that followed, organizations such as the Institute for Safe Medication Practice (ISMP) (2005) and The Joint Commission on Accreditation of Healthcare Organizations (formerly JCAHO) (2006) have consistently supported limiting the use of abbreviations and acronyms. The consciousness of the healthcare community has been raised, yet the threat to patient safety continues.
Abbreviations and Acronyms
The term abbreviation is derived from the Latin brevis, or short (The American Heritage Dictionary of the English Language, 2000). More specifically, it is a letter or a group of letters used to represent an entire word. Early use of abbreviations can be found in medieval Latin manuscripts (Bloom, 2000). Materials such as stone, marble, bronze, or parchment were scarce. This may have contributed to the need to fit large quantities of text onto limited, precious space by the third or fourth century (Scribal Abbreviations, 2006). Many years later the medical community used the abbreviation in classification systems such as the periodic table as well as geneses of plants and animal species (Bloom, 2000).
The practice of abbreviating continues for similar reasons with the art of text paging on small cell phone screens by hurried 21st centurions. Abbreviation downloads are available for purchase on-line for Personal Digital Assistants (PDA) (Astra Zeneca, 2006). E-mail is in itself an abbreviation and has offered a whole new language of abbreviation, as well as limiting capitalization and punctuation. In a sense, the acronym is a combination of abbreviations that form a new word with a separate meaning. The word acronym is derived from the Greek akros, meaning top-most or extreme and onoma, meaning name. In this country the acronym’s component letters usually result in a pronounceable word (Acronyms and Initialism, 2006). Although acronyms can be found dating back almost as far as abbreviations, their widespread use is a 20th century linguistic phenomenon. Com mon examples include RADAR, LASER, and NATO. They have be come such an accepted part of language that often the capitalization of letters and punctuation has been dropped and many users can not verbalize what the initials originally indicated.
The benefits of the use of abbreviation and acronyms in general documentation may appear obvious. In the case of abbreviations, they have not changed over centuries. Abbreviations and acronyms are short, space-saving, convenient and easy to use. They are simple and hard to misspell. They also may be exclusive, and therefore understandable only to a specific group of professionals (Kushlan, 1995).
The Patient Safety Issue in Healthcare
Regardless of their convenience, medical abbreviations have been responsible for serious errors and deaths. According to the Institute for Safe Medication Practices (ISMP) over 7,000 deaths per year may be attributed to medication errors (Brehio, 2005). The use of abbreviation and medical notation makes a significant contribution to this statistic. The literature is filled with many examples of the problems arising from their use. The following are examples of the most common problem-types grouped for organization and clarity.
Ambiguity. Abbreviations or acronyms can stand for more than one word and therefore can be misinterpreted. In the introductory pediatric anecdote CP stood for Cleft Palate in the mind of the initial author, but was perpetuated as Cerebral Palsy. A query of an on-line medical dictionary of abbreviations using the abbreviation CP yielded 79 medical phrases for CP (Astra Zeneca, 2006). In addition to those mentioned, some of the more common were chest pain, candle power, cardiac pacing, chicken pox, child psychiatry, creatinine phosphate, and current practice. The problem crosses specialties and oceans. Manzur, Nair, Govind, Pai, and Al-Khusaiby (2004) conducted a small chart-review survey in a neonatal unit in the Sultanate of Oman. Their analysis of the 1-day use of abbreviations by seven physicians at various levels of training found an alarming use of ambiguous abbreviations. Interestingly the first listed was CP intending to stand for Crystalline Penicillin. Similarly, acronyms often are used ambiguously in clinical research trials. Fred and Cheng (2003) catalogued 16 separate cardiac trials all using the acronym HEART. Without further definition one would be unable to tell which trial is referenced. These authors suggest that the acronym itself is not the issue but rather the failure to define its meaning.
Unfamiliar abbreviations. A reality of healthcare today is the specialized nature of individual services and disciplines. A study in the United Kingdom examined physicians’ understanding of Ear, Nose, and Throat (ENT) surgical abbreviations (Das-Purkayastha, McLeod, & Canter, 2004). Physicians-in-training who rotated among specialties, but were not familiar with otolaryngology, completed a questionnaire to determine knowledge of their specialized abbreviations. Six of the 13 commonly used abbreviations were unclear to 90% of these doctors in other specialties. This has similar implications for nurses floating from one unit to another. What is obvious to one specialty may be obscure to another. House staff travel also among various institutions in the same city or region and may leave a legacy of new and unfamiliar abbreviations for the next generation to decipher (Calfee, 1997). They also may be interpreted based on knowledge gained in another specialty, therefore qualifying them as ambiguous. Using a global example, many abbreviations used in the United Kingdom routinely, for example CP for Crystalline Penicillin, would take on other meanings in the United States. Cheng (1999) suggests that the use of acronyms has become such a competitive game that the clinical trial may be named to match a clever acronym already created.
Look-alike abbreviations. Throughout the healthcare literature are widespread examples of common errors due to look-alike abbreviations or symbols. These problems involve numbers as well as letters. 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”(Institute for Safe Medication Practices, 2001). In this case .5 milligrams was misinterpreted in transcription as 5 milligrams. A nurse who was unfamiliar with pediatric dosing administered the morphine. A leading zero would have avoided this error. Sadly, a similar error was identified as one of the first openly reported medication safety errors 30 years earlier. Another event involved the Latin phrase per os (by mouth) written as part of a medication order and read as O.S. (oculus sinister) or left eye (Karch & Karch, 2003). Although the context might have helped clarify in this case, a new practitioner was confused by the ordered route.
The ISMP has recorded many events involving the use of the Greek letter m (the symbol for micrograms), as well as u (an abbreviation for units). In several orders for heparin and insulin the handwritten u was closed at the top and misinterpreted as another 0 therefore increasing the dose by a multiple of 10 (Paparella, 2004). The issue of look-alike abbreviations also speaks to the issue of handwriting. The closer the symbols appear, the more chance for error. In using abbreviations there are fewer clues to the intended meaning of the word. The use of computerized records may alleviate some of these opportunities for error (Whyte, 2005). In a letter reporting the experience of a 150-bed rehabilitation hospital, medical errors were reduced by 62% in a 1-year period (Grandville, Molinari, & Campbell, et al., 2006). A 2005 prospective study conducted in an intensive care unit compared the effects of computerized provider order entry (CPOE) with handwritten prescribing. The authors found that significantly fewer medical errors occurred overall with CPOE (4.8% versus 6.7%). When they combined intercepted and non-intercepted errors, CPOE’s value appeared to increase; the significance also improved over time, presumed to be related to a learning curve. While these numbers may have been impressive, all three of the intercepted errors which might have caused the most significant harm to patients occurred using CPOE (Shulman, Singer, & Goldstone, et al., 2005). Neither of these studies specifically addressed the errors believed to be related to the use or misuse of abbreviations.
A year following the death of the 9 month old issued as a Sentinel Event Alert by the ISMP, The Joint Commission’s Board of commissioners authorized the development of a National Patient Safety Goal focusing on the creation of a “do not use” abbreviation list. In 2004 The Joint Commission introduced the official list (see Table 1 ) as part of the requirement for meeting Patient Safety Goal 2b, a subset of the Communication goal (The Joint Commission on Accreditation of Healthcare Organizations, 2006). It mandated institutions to standardize a list of abbreviations, acronyms, and symbols that were not to be used throughout any accredited organization.
The National Summit on Medical Abbreviations convened in November of 2004. The participants included representatives from more than 70 professional associations including the Institute for Safe Medication Practices, the American Hospital Association, the American Medical Association, and the American Society of Health-System Pharmacists. The American Academy of Nurse Practitioners, the American Association of Nurse Anesthetists, the American Colleges of Nursing, and the American Nurses Association, among others, represented the nursing profession (C. Wong, personal communication, March 28, 2006). In addition to reaffirming the “do not use” list, the summit participants defined the scope of requirements necessary to maintain accreditation. For example, they designated that the prohibition of specified abbreviations would apply to all orders and all medication documentation both handwritten and free-text computer entry. They specified that the exclusion also would apply to all preprinted forms. The minimum compliance rates were set at 90% for handwritten and free-text orders, and 100% for pre-printed forms by 2005.
The summit recommendations did not support the use of an approved list of abbreviations; however, many institutions currently have such a list. Actually, the standards call for standardization of terminology, abbreviations, and acronyms within and among institutions, which may have been interpreted as necessitating such a list. This practice has not been required since 1991, but arguably the terminology is confusing. The ISMP(2005) published a list of error-prone abbreviations. It encompasses The Joint Commission list, but is far more extensive (see Table 2 ). It is based on data received through their error reporting program. The ISMP strongly recommends prohibiting the use of items specified on this list when communicating medical information. In addition, they stipulate these communication mechanisms: labeling, prescriptions, computer order entry screens, etc.
JCAHO (now The Joint Com mission) and ISMP, ironically still known by their acronym and abbreviated titles, set the standards for safe practice regarding abbreviation usage in a small sub-set of admittedly the most common occurrences. However, neither of these prestigious organizations addresses the full scope of the abbreviation and acronym problem either alone or together. The patient safety threat remains. Failure to eliminate “do not use” abbreviations is one of the most frequent Joint Commission survey occurrences, at 27% (The Joint Commission on Accreditation of Healthcare Organizations, 2006). These organizations have provided the standard that will inspire many institutions and professional organizations to design creative solutions and best practices, which in turn will support patient safety. In the literature, there are three strategies aimed at solving this patient safety problem: education, enforcement and leadership.
Education. In addition to issuing its widely publicized list of dangerous abbreviations, the ISMP (2005) has taken a leading role in education. Beginning in 2006, they recommended that the list be referenced whenever and wherever medical information is documented. The targeted audiences include all healthcare professionals and students, as well as medical writers, the pharmaceutical industry, and the Food and Drug Administration staff (FDA). In conjunction with the FDA, the ISMP plans to develop a campaign of educational materials, presentations at conferences, and articles in professional journals (Brehio, 2005). All educational materials will be both online and in print. The ISMP has collected data on medication errors since 1996 and has published Medication Safety Alerts in newsletters and electronic forms for reprint and circulation. These are reports of compromised patient safety incidents available for education of the healthcare community and the public.
Private education programs targeting patient safety are available for sale at national conferences and often at no-cost online. A World Wide Web query using the terms abbreviations + patient safety yields many individual healthcare system’s clever education tips and tool kits. These attempt to minimize the use of abbreviations with the goal of patient safety and Joint Commission compliance (Ohioans First, 2003). The Madison Patient Safety Collaborative (2006) boasts pocket cards, Power-Points, a safety week, posters, fluorescent stickers and letters from key influential personnel detailing education and awareness tactics on their web page. Joint Commission International for Patient Safety (2006) surveyed accredited organizations and published a list of similar tips. Twenty-one of the 27 tips were educational interventions. Many of these involved a prominent and/or clever display of the “do not use” list.
Enforcement. The clearest example of this type of solution is The Joint Commission itself. The Joint Com mission called for 90% (handwritten and computer free-text) and 100% (pre-printed form) compliance rates with the “do not use” abbreviation list for 2005. The direction is quite apparent. Comply or potentially lose accreditation. The previously mentioned list of tips to eliminate dangerous abbreviations includes the suggestion that pharmacy orders with dangerous abbreviations be corrected before being dispensed (Joint Commission International Center for Patient Safety, 2006). This “big-stick” approach has been difficult to implement at the institution or healthcare system level.
Safest in America, a collaborative partnership between Children’s Hospitals and Clinics in Minneapolis and other area hospitals instituted a relentless educational effort to change unacceptable abbreviation practices in the area of prescriptions (Traynor, 2004). The consortium found that the educational effects could not be sustained and therefore did not eliminate the problem. In April 2004 the consortium mandated that all medication orders containing unacceptable abbreviations would be invalid and would need to be rewritten. The remedial process was arduous. Another hospital used a similar approach and reduced its medication orders containing unacceptable abbreviations from 30% to 6% in 4 months (Traynor, 2004). Exhaustive educational efforts had previously been abandoned also. In this case the pharmacy compiled lists of offenders and routed them through the chair of the specific department. In this way, physician ownership became a more powerful tool. A third hospital used a similar system but stopped short of rendering the order invalid. Letters were sent back to the author of the offending abbreviation in an effort to remediate. No decrease in the use of unacceptable abbreviations resulted.
The ISMP (2004)reported that another method of enforcement involved requiring nurses to notify physicians of abbreviation errors. This is at best a burdensome, inappropriate solution; the ISMP agreed. Other forms of enforcement are less blatant. In a sense, properly designed pre-printed documents and charting records are a form of enforcement. Such forms prevent the use of abbreviations by limiting free text, offering check-off boxes and circle options (Holland, 2001). Alternatively, when abbreviations are used their meanings may be designated on the form in a similar way the electronic record also may afford some limited protection against the use of dangerous abbreviations. Some limitations are inherent in the number of characters allowed by some software, though (Unknown, 2005). The ISMP warns that there be one standard for abbreviations, that an electronic record alone is not a solution (Institute for Safe Medication Practices, 2002). A British study compared documentation in a pediatric intensive care unit (PICU) that used handwritten records to that of a step-down unit (HDU-high dependency unit) that used electronic records, and reported that 92% of all documentation contained abbreviations, or abbreviated words, regardless of the system used (Whyte, 2005).
Leadership. The influence of leading by example is possibly the most subtle but effective strategy. It is less coercive but more far-reaching. In the previously mentioned education example, the ISMP partnered with the FDA to launch an education campaign. This is an excellent example of taking a stand and leading by example. Healthcare providers are taking a stand in their respective professional organizations by asking their journals to take a proactive approach to patient safety by reducing or eliminating abbreviations (Meyer & Villamaria, 2004). Others have suggested publishing a list of accepted specialty abbreviations and their meanings in the back of each journal (Bloom, 2000). Still others call for unilateral standardization (Beyea, 2004; Institute for Safe Medication Practices, 2002).
There are those who appear to be undecided as to appropriate path for clarity. Das-Purkayastha, Mcleod and Canter(2004) state that the solution is either to ban abbreviations or to distribute a list of acceptable ones. Many style manuals and journals have taken a partial stand for decades. The American Psychological Association (APA) warns to use them “sparingly”(American Psychological Association, 2002). The Journal of the American Medical Association (JAMA) prohibits the use of abbreviations in the title or abstracts but asks that they be “limited” in the text (JAMA, 2007). Kushlan (1995) suggested that the issue is not the abbreviation itself, but the lack of definition. He recommends that abbreviations can be used safely if they are defined when first introduced and then may be used repeatedly in one source. JAMA (2007) also mandates this in its instructions to authors. This concept may be suited to journals but has little relevance to orders and charting. Fred and Cheng (2003) apply the same logic to the world of acronyms in clinical trials. Another example of leading by example is the adoption and support of a just or blameless culture (Marx, 2001). Healthcare executives who encourage the safe reporting of medical errors create an atmosphere of trust in which education and even enforcement can thrive. The more abbreviation errors are reported, the more is learned, the more solutions become evident.
Abbreviations are simply a concrete example of barriers to clear communication. No one strategy aimed at eliminating dangerous abbreviations appears to ensure a better patient safety outcome. A culture change is a slow but hopefully inevitable process. The “do not use” list is an excellent beginning, but it is not enough. If used appropriately it is aimed at protecting against only one problem, medication errors. Admittedly, medication errors are an extremely important category of errors. The misuse of CP in an 8-year-old child described earlier was initiated in his initial history and physical. Although not a medication error, its potential consequences were as significant.
Standardization is paramount and will require practice changes for all healthcare providers. Both the problems and the solutions are multidisciplinary. Healthcare is an international, multi-disciplinary community. Electronic communication has allowed access among healthcare partners globally. Rather than multiple secret abbreviated codes, providers must speak and understand a common, clear language in the name of the safety of patients. In addition, it is clear that the process must start much earlier. Enforcement of imposed guidelines, no matter how appropriate, has proven unsuccessful and painful to all involved. The elimination of the use of abbreviations must begin in Nursing, Medical, and Pharmacy curricula and in all healthcare education programs. It can begin in all professional journals one abbreviation or acronym at a time, spelled-out for clarity and most of all safety. Authors and editors must set the standard and accept nothing less.
Nurses can begin in their practice by using the full descriptive language of their profession to communicate patients’ needs clearly and directly and by questioning when in doubt. Staff nurses must be empowered to do this. Nurse Managers must support this and implement changes in electronic communication wisely, always with the goal of maximizing patient safety. Nursing faculty must teach this. Advanced practice nurses must model this and set the standard for other healthcare providers to follow. Research must be conducted to provide the evidence to support the standards. Nurses must sit on the decision-making boards that set standards of care in hospitals and healthcare systems so that the change in culture can happen. All nurses must educate, enforce, and most of all lead.
The print version of this article was originally certified for CE (continuing education) credit. For accreditation details, please contact the publisher, Anthony J.
Table 1. The Joint Commission on Accreditation of Healthcare Organizations´ Official “Do Not Use’ List for Abbreviations1
Table 2. Institute for Safe Medication Practices´ Error-Prone Abbreviations, Symbols and Dose Designations Institute for Safe Medication Practices
Jake was an 8-year-old male who arrived to the Perioperative area of a pediatric tertiary care center for his short procedure. He was a precocious child who interacted well with staff and, in particular, required detailed scientific explanations of the steps involved in and events leading up to his surgery. Our stretcher ride to the Operating Room (OR) was complemented by questions and developmentally adjusted answers about the procedure, the players, the timing, pain concerns, and an 8-year-old´s fascination with the world of technology. As we entered the OR the chatter continued. The induction of anesthesia was smooth. My colleagues were respectful, and child-focused, cooperating fully with our usual astronaut trip from Philadelphia to the moon, the destination reflecting of the age of the nursing staff present. An anesthesia colleague commented on our choice of distraction techniques for a child with MRCP. Wrong child, I thought. He persisted. This might have been a usual case in a usual day in the life of the operating room, except that the documentation in the chart, both hand-written and more recent electronic records, matched his comment. It read, “8-year-old male, with MRCP….”
Old charts always accompany patients to surgery. Page after page from the present back in time contained notations, which included the term MRCP, an abbreviation commonly, used to denote: Mentally Retarded/Cerebral Palsy. His clinical presentation was in obvious contrast with this diagnosis. Persistence and time allowed us to uncover 4 years of entries containing the abbreviation MRCP, until we noticed MRCP had been preceded by CP for several notations. The first chart entry read “Infant with Cleft Palate.”
DisclaimerThe authors reported no actual or potential conflict of interest in relation to this continuing nursing education article.
Ivy Fenton Kuhn, MSN, CRNP, CNOR, is Pediatric Nurse Practitioner, The Children´s Hospital of Philadelphia, Philadelphia, PA. The author was an MSN candidate at the School of Nursing of The University of Pennsylvania at the time this article was written.
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