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Ken Margolin
Ken Margolin
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Medication Errors Due to Dangerous Abbreviations

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The pharmaceutical industry and medical profession have known for years that the misinterpretation of medical abbreviations can cause injury or death. Fixing the problem is much more difficult than identifying it. Medications are manufactured by any of numerous pharmaceutical companies, and are dispensed by tens or hundreds of thousands of health care professionals.

Names of completely different drugs with different purposes, may be similar, as well as their abbreviations. When handwriting is used, legibility can be a dangerous problem. Imposing absolute uniformity in the use of abbreviations may be an impossible task. The Institute for Safe Medication Practices (ISMP), a non-profit organization dedicated, as its name suggests, to promoting safer medication practices, issued a special alert containing a “Do Not Use” list of 41 abbreviations or dose designations to be avoided. For example, the abbreviation “D/C,” seen in innumerable patient medical charts, should not be used. According to ISMP, “D/C” is sometimes intended to mean “discharge,” and other times, to mean, “discontinue.” A dangerous event can occur when “D/C” followed by a list of drugs, means, discharge with the following medications, but instead is interpreted to mean discontinuation of the medications. “DPT” may be intended to mean demerol-phenergan-Thorazine, but interpreted to mean the diphtheria-pertussis-tetanus vaccine. “HCT” intended to mean hydrocortisone, has been misinterpreted to mean hydrochlorothiazide. The solution in each of the preceding instances, and in many others, is to write out completely that which is intended, rather than to rely on abbreviations. Plain English usually works best to convey meaning. But, abbreviations, dashed onto a medical record, saves time, even though the impression of time-saving, is far more than the second or so actually saved.

The dangers of mis-interpreted medical abbreviations, has been identified by the federal Food and Drug Administration (FDA), as well as by ISMP, and by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the health care industry’s licensing arm. The differences in the lists highlighted by ISMP, FDA, and JCAHO, illustrates how difficult achieving consensus in the use or non-use of abbreviations will be. In contrast to ISMP’s list of 41 “do not use” abbreviations, JCAHO currently includes only 7, with another 7 listed “for possible future inclusion in the Official “Do Not Use” list. The FDA “Safety Page,” titled, “Stemming Drug Errors from Abbreviations,” mentions 18 abbreviations to be avoided. It may well be that one of the ongoing recommendations to reduce a variety of medication errors – changing the relevant culture – might ultimately be the best solution. The message must be drilled into healthcare professionals that hasty entries into a medical chart may have disasterous consequences. Enough time must be spent to make sure that every entry is legible, accurate, and impossible to misinterpret.