The ISMP, Dangerous Abbreviations....and You!

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.

The list can be found here:  http://www.ismp-canada.org/download/ISMPCanadaListOfDangerousAbbreviations.pdf

 

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!)

The ISMP list of dangerous abbreviations from the United States can be found here:  https://www.ismp.org/tools/errorproneabbreviations.pdf

 

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.

-  This dearth of Canadian data can seen in Accreditation Canada’s Required Organizational Practice (ROP) entitled “Dangerous Abbreviations”, where only data from the United States is used when discussing the cost and extent of medication errors.  (http://www.accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf )

 

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.

-  ( FYI.  The Joint Commission makes an excellent point about certain exceptions to the “Trailing zeros” rule – for non-medication documentation.  That can be found in this document:  http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf )

 

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:

-  You can also report medication errors or other concerning issues with medications via http://safemedicationuse.ca/index.html

-  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 Canada – http://www.ismp-canada.org/index.htm  (Large variety of information for healthcare professionals.)

SafeMedicationUse.ca - http://safemedicationuse.ca/index.html  (Large variety of information for consumers.)

ISMP - http://ismp.org/  (Large variety of information for healthcare professionals.)  (Based in the United States.)