In a 2005 study done by Koczmara and associates (2005), they concluded that most of the errors in the writing and reading of medication is associated with the use of abbreviations. The source of errors was based on reported “misreading” of the abbreviations used, discrepancies in the use of the abbreviations, as well as clerical and typographical errors (Greenal, 2006). The ISMP (2003) has seen the need for professional and health institutions to respond to the issue by developing better professional and practice standards to limit discrepancies in medication interpretation.
However, there is also a realization that such institutions currently lack the ability or capacity to do so. A reason that has been seen is that health and other related institutions have generally been reactive to changes to pharmaceutical retail industry. There has been concern that accrediting and regulatory agencies’ responses to concerns have been limited to only the reported cases and few preventive measures. Currently, provisions on medication only prescribe for a “degree of accuracy, completeness, and discrimination necessary for their intended use” (ISMP, 2003).
An area of particular concern has been the lack of responsiveness to the impact of technology to medication orders. In a study of medication errors in pediatric critical care units, majority of the errors indicated errors developed from entry process of medication orders (Potts et al, 2004). Thus, errors were operational rather than deficiencies in medical professional practice. On the other hand, there are some sources of errors that have remained persistent. The persistence of such “error-prone abbreviations” creates vulnerabilities in communication and interpretation of orders (Koczmara et al, 2005).
The US Joint Commission (2001) admits that there are deficiencies in current standards and point out that measures that have to be undertaken require the cooperation of all stakeholders in the industry. In a statement by ISMP President Michael Cohen citing his association’s three decade effort regarding the issue that it is “important to avoid these dangerous abbreviations and dose expressions in other communications such as computer-generated labels, Medication Administration Records (MARs), labels for drug storage bins/shelves, preprinted orders and protocols, and pharmacy and prescriber order entry screens (ISMP, 2003).
Suggestions to address the issue include review on methodologies concerned with pharmaceutical labeling, medication construction and communication and professional and industrial monitoring. Moreover, there has been little cohesion in the efforts to augment the problem. Often, professional medical associations and regulatory institutions have placed the burden of blame on the order and in general have acted independently of each other.
Greenal (2006) further points out that the issue should only be considered as medical or industrial concern by pharmaceuticals but should consider an urgent and critical public health risk as well as a major determent to confidence in healthcare systems. According to the Institute for Safe Medication Practices (ISMP) (2003), this requires a review of professional education and practice standards, responding to developing retail and market channels, increasing public awareness and developing social programs to address issues and concerns.
In conclusion, the need to improve and increase the efficiency of medical professionals writing and reading medication orders has been highlighted the increase of incidence of injury or even death.
References
Greenal, Julie (2006). Need to eliminate dangerous abbreviations in medication orders. Hospital News, December. p. 14 Institute for Safe Medication Practices (2003). It’s time for standards to improve safety with electronic communication of medication orders. Retrieved June 18, 2008, from http://www. ismp. org/Newsletters/acutecare/articles/20030220. asp? ptr=y Koczmara, C., Jelincic, V. , Dueck, C. (2005). Dangerous abbreviations: “U” can make a difference! Dynamics, Fall,16(3). pp. 11-5. Potts, A. L. , Barr, F. E. , Gregory, D. F. , Wright, L, Patel, N. R. (2004). Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics, 113(1 Pt 1). pp. 59-63. US Joint Commission (2001). Medication errors related to potentially dangerous abbreviations. Sentinel Event Alert, Issue 23, September 1. Retrieved June 18, 2008, from http://www. jointcommission. org/SentinelEvents/SentinelEventAlert/sea_23. htm