The ISMP,
Dangerous Abbreviations…and you.
What
is the ISMP?
The ISMP is the “Institute
for Safe Medication Practices” – and is based in the United States.
In Canada, we have
the Institute for Safe Medication
Practices (ISMP) Canada.
As per ISMP Canada,
The Institute for Safe Medication Practices Canada is an independent
national not-for-profit organization committed to the advancement of medication
safety in all healthcare settings. ISMP Canada works collaboratively with the
healthcare community, regulatory agencies and policy makers, provincial,
national and international patient safety organizations, the pharmaceutical
industry and the public to promote safe medication practices. ISMP Canada's
mandate includes analyzing medication incidents, making recommendations for the
prevention of harmful medication incidents, and facilitating quality
improvement initiatives.
What
is the “Dangerous Abbreviations List” about?
As per ISMP Canada,
The use of some abbreviations, symbols, and dose designations has been
identified as an underlying cause of serious, even fatal medication errors.
What
is the difference between the United States ISMP list of dangerous
abbreviations and the ISMP Canada list?
The ISMP list of
dangerous abbreviations in the United States is somewhat more extensive in its
list of abbreviations, and also gives numerous additional examples of dangerous
abbreviations for medication names – where the ISMP Canada list only gives three
examples of dangerous abbreviations for medication names. (Sadly, some Canadian hospitals haven’t even mastered not using those
three!)
Why
might the list in the United States be longer?
Both the ISMP and
ISMP Canada formulate their lists based on events that have already occurred
(i.e. where the error has already reached and possibly harmed the patient), as
well as “near-misses” – if they feel it warrants an addition to the list.
In the United
States there are various federal and state mandatory reporting requirements for
medication and other medical errors – providing a significant pool of data for
the ISMP to use in gathering this information.
The same cannot be
said for Canada – where reporting of errors is strictly voluntary.
Are
there other dangerous abbreviations that should be added to both the ISMP and ISMP
Canada lists of dangerous abbreviations?
I propose the
following should be added to both
lists:
- “GM”, “Gm”, “G”, or “gm” for gram(s)
- The metric (or SI) abbreviation
for gram(s) is “g”.
- In the metric system - gram,
meter, and litre are all abbreviated as single lower-case letters (“g”, “m”,
and “l” respectively), and prefixes such as kilo-, milli-, micro-, etc. are
added to further quantify them.
- When typing, transposition
errors (i.e. accidently switching the order of letters) can and does
occur. Accidently switching “gm” with “mg”
(or visa versa) would result in a 1000 times dose difference!
- Having “GM” or “Gm” as an abbreviation
for grams in a menu in electronic documentation or medication dispensing systems
can lead to confusion.
- I have on many occasions seen
nurses accidently select the incorrect unit and document “2mg” (2 milligrams) as the dose given when 2 grams was ordered. Having “g” for grams also sets it apart from “mg”
– as a single letter is difficult to confuse with two letters.
- In the metric system, the upper-case
“G” is used for the prefix “Giga-“ - so
the abbreviation “Gm” would refer to “gigameter”.
- (As an aside, it may be appropriate to use the uppercase "L" for litre in written orders and documentation - as the lowercase "l" may easily be confused with the number "1".)
- “w/”,
“w/o”,
or “w”
with
a line above it for without
- There are so many variations of abbreviations for “without” that it can lead to confusion.
- Arguably, an acceptable medical
abbreviation for “without” has historically
been “s” with a line above it (with “s” referring to the Latin word “sine”).
- [“c” with a line above it has
historically been used as the medical abbreviation for “with” (with “c” referring to the Latin word “cum” - pronounced “coom”)].
- “NAC” for the medication acetylcysteine (an antidote for
acetaminophen overdose).
- Although this abbreviation is
somewhat dated/archaic, it is still used on orders and documentation at some
hospitals.
- This abbreviation is used in
academic literature and research, but should not be used in the clinical setting.
- If a patient was transferred
from a hospital using “NAC” as an abbreviation to another hospital, or another
hospital requests records from a hospital that uses “NAC” as an abbreviation –
many at the other facility would not likely know what this abbreviation refers
to.
- Abbreviations for the names of
medications should never be
used!
- “GTN” for the medication nitroglycerin.
- Although this abbreviation is
somewhat dated/archaic, it is also still used on orders and documentation at
some hospitals.
- If a patient was transferred
from a hospital using “GTN” as an abbreviation to another hospital, or another
hospital requests records from a hospital that uses “GTN” as an abbreviation –
many at the other facility would not likely know what this abbreviation refers
to.
- Abbreviations for the names of
medications should never be
used!
- “cc” (for cubic centimetres) for millilitres (ml)
- [Clarification of existing item on list] – I have seen the
handwritten “cc” after the dosage (i.e. 10cc) mistaken for zeros – making it a 100
times dose difference!
- I have seen this error occur in
practice settings where I have worked in both the United States and Canada –
yet neither the ISMP nor ISMP Canada have picked up on this.
- [This
is not an exhaustive list by any means!]
- The only
exception for the use of an abbreviation for a medication is “ASA” for aspirin (aka acetylsalicylic acid) – as “ASA” is universally understood as referring to aspirin in healthcare in North America.
Are
there other problems with the lists?
As stated earlier,
both the ISMP and ISMP Canada formulate their lists based on events that have
already occurred – meaning that these lists are reactive in nature instead of proactive.
- In Canada this presents an
additional problem since (as was stated earlier) reporting of medication
incidents is completely voluntary – so the data, more often than not, never
reaches ISMP Canada for consideration and possible inclusion on this list.
- I have seen multiple errors
associated with all of the aforementioned additional abbreviations suggested in
this blog entry, in practice settings in both the United States and
Canada. These occur in orders, written
documentation, electronic documentation, and medication dispensing systems in
both countries – yet have somehow escaped the notice of both the ISMP and ISMP
Canada (as well as Accreditation Canada and the Joint Commission).
- Sadly, with their reactive
mandate, we will have to wait for a patient to be harmed or die from an error
related to these abbreviations before they are added to the list(s).
Where do we go from here?
Hospitals and
other healthcare organizations:
- The aforementioned list(s) of
dangerous abbreviations from the ISMP and ISMP Canada are minimum standards. In Canada, it would be wise for hospitals to
adopt the additional items in the ISMP list from the United States, the additional
examples given in this blog post, and any additional problematic abbreviations
that are found within your organization.
- Share these additional
problematic abbreviations with ISMP Canada.
- Regularly audit your order
sets, written documentation by physicians and staff, electronic documentation
systems, automated medication dispensing systems, and pharmacy systems for use
of dangerous abbreviations.
- Inform ISMP Canada of common or
unique medication incidents – as other organizations and individual healthcare
professionals can learn from these and further increase patient safety.
- Other problems with medications
(i.e. formulations that cause difficulty with administration, faulty
containers, problems with syringes or needles, etc.) can and should also be
reported to ISMP Canada.
- Think about unique abbreviations
used in orders and documentation at your facility – and whether staff at
another facility would understand those abbreviations if your patient were transferred
there or presented there and that other facility is requesting patient records
from your facility.
Healthcare
professionals:
- Even if your hospital or other healthcare
organization does not adopt these additional dangerous abbreviations into their
“Do NOT Use” list – you should not be using them. This is
your professional responsibility!
- Many of you have not even mastered the ISMP Canada “Do
Not Use” list of dangerous abbreviations yet.
Get on board! This is your professional responsibility!
- You too can and should report common
or unique medication incidents to ISMP Canada – as other organizations and
individual healthcare professionals can learn from these and further increase
patient safety. (This is a confidential process and does not
involve identifying a patient – so there is no violation of privacy
legislation. You do not need your employer’s permission to do this.)
- Other problems with medications
(i.e. formulations that cause difficulty with administration, faulty
containers, etc.) can and should also be reported to ISMP Canada. (This is also a confidential process and does not involve identifying a
patient – so there is no violation of privacy legislation. You do not
need your employer’s permission to do this.)
- Think about unique abbreviations
you use in orders and documentation at your facility – and whether staff at
another facility would understand those abbreviations if your patient were transferred
there or presented there and that other facility is requesting patient records
from your facility.
ISMP and ISMP
Canada:
- Are you really going to wait
for a patient to be harmed or die from an error related to the additional
abbreviations suggested in this blog entry before they are added to the
list(s)?
- ISMP Canada: Are you
really going to wait for a patient to be harmed or die from an error related to
the additional abbreviations on the ISMP list of dangerous abbreviations from
the United States before they are added to the ISMP Canada list of dangerous
abbreviations?
System
Administrator for electronic documentation and automated medication dispensing systems:
- Electronic documentation
systems (i.e. Eclipsys Sunrise Clinical Manager (SCM), Meditech,
etc.), automated medication dispensing systems (i.e. Omnicell, Pyxis, etc.), and
Pharmacy Department systems.- all need to ensure that the dangerous
abbreviations from the ISMP list from the United States, as well as the
additional abbreviations suggested in this blog entry are not utilized.
- “GM’, “Gm”, and “G” used
erroneously for “grams” (g) is
a common error in many of the aforementioned systems.
Patients,
patient family members, and the lay public:
- There are also plenty of other
useful and informative resources on this website.
Patients, patient
family members, the lay public, media, and healthcare professionals in Canada:
- Ask your MP, MPP, and federal
and provincial ministers of health to require reporting of medication and
medical errors (without patient identification) – to improve patient safety.
Links:
ISMP - http://ismp.org/ (Large variety of information for
healthcare professionals.)
(Based in the United States.)
