Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Administrative Manual MHS SMOL Subject: ABBREVIATIONS/ACRONYMS/SYMBOLS Number: ADM-PHI-20 Section: Personal Health Information/Privacy Page 1 of 1 Initial Approval Date: November 29, 2007 Review Date: June 25, 2012 Revised Date: June 25, 2009 Approved by: Senior Leadership Team Prepared by: Patient Records Committee Director, Quality & Risk Management Policy Coordinator Endorsed by: Patient Records Committee – May 23, 2009 Professional Advisory Committee – June 19, 2009 Issued by: Vice President of Finance, Information Management and Chief Financial Officer POLICY Purpose: The purpose of this policy is: ▪ To provide direction regarding the use of abbreviations/acronyms/symbols in the personal health information (PHI) record, specifically to implement Institute for Safe Medication Practice’s ‘Do Not Use’ list and list of ‘Error-Prone Abbreviations, Symbols, and Dose Designations’. ▪ To define specific key documents in which abbreviations are prohibited and to discourage their use throughout the remainder of the personal health information record to manage the risk arising from the misinterpretation of abbreviations. Policy Statement: Drug names will not be abbreviated. Drug names, dosage units, and directions for use will be written out fully without the use of abbreviations, symbols, and dose designations in orders, computer-generated labels, medication administration records, storage bins, shelf labels, and reprinted protocols. Abbreviations, acronyms and symbols are not permitted in the following contexts and/or reports: ▪ ▪ ▪ ▪ The recording of the final diagnosis or in the description of treatment procedures. The discharge/front sheet or discharge summary. The wording of consents. Units of measurement must conform to the Metric System International (SI) units. The use of abbreviations and/or acronyms is discouraged in the remainder of the personal health information record. When an abbreviation is used, it must be preceded by the word(s) fully written out, e.g. personal health information record (PHI) record. The abbreviation or acronym can only be used in the same documentation event. Administrative Manual MHS SMOL Subject: ABBREVIATIONS/ACRONYMS/SYMBOLS Number: ADM-PHI-20 Section: Personal Health Information/Privacy Prepared by: Patient Records Committee Director, Quality & Risk Management Policy Coordinator Endorsed by: Patient Records Committee – May 23, 2009 Professional Advisory Committee – June 19, 2009 Issued by: Page 1 of 2 Initial Approval Date: November 29, 2007 Review Date: June 25, 2012 Revised Date: June 25, 2009 Approved by: Senior Leadership Team Vice President of Finance, Information Management and Chief Financial Officer PROCEDURE Step Action Responsibility 1. Be aware of the Institute for Safe Medication Practices ‘Do Not Use’ list (Appendix 1), and the ‘List of Error-Prone Abbreviations, Symbols and Dose Designations’ (Appendix 2), and do not use abbreviations, symbols and dose designations in your practice. All Clinicians 2. Conduct a random audit of consent forms, description of treatment procedures and discharge summaries, and discharged and concurrent records on a quarterly basis for each program and/or service. 3. Audit all orders received for use of abbreviations listed in the ‘Do Not Use’ list. Contact physicians/nurse practitioner to clarify the order before processing. Pharmacy Staff 4. Audit documentation in the client’s personal health information record for the use of abbreviations, acronyms, and symbols. Report findings to the Program/Team Manager. Assigned Staff 5. Distribute the findings to the Service Chiefs/Clinical Program Directors/Leaders. Patient Records & Registration Services 6. Document follow up and actions taken for instances of noncompliance to the policy, including coaching/mentoring/ information sharing/education. Service Chiefs/ Clinical Program Directors/Leaders 7. Provide documentation of action taken to the Patient Records Committee for reporting to the Professional Advisory Committee Service Chiefs/ Clinical Program Directors/Leaders Patient Records & Registration Services Step Action References: Institute for Safe Medication Practices Canada ‘Do Not Use Dangerous Abbreviations, Symbols and Dose Designations’ www.ismp-canada.org/dangerousabbreviations.htm Institute for Safe Medication Practices Canada ‘ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations’ www.ismp.org Religious Hospitallers of Saint Joseph of the Hotel Dieu of Kingston, Administrative Policy #2820 ‘Interprofessional Documentation: Minimum Standards’ Cross-References: Providence Care Clinical Practice Manual Policy and Procedure #CLIN-PP-54 ‘Safety Reporting and Incident Management’ Subject: ABBREVIATIONS/ACRONYMS/SYMBOLS Procedure #ADM-PHI-20 Page 2 of 2 Responsibility Providence Care Abbreviations/Acronyms/Symbols #ADM-PHI-20 Appendix 1 Do Not Use Dangerous Abbreviations, Symbols and Dose Designations The abbreviations, symbols, and dose designations found in this table have been reported as being frequently misinterpreted and involved in harmful medication errors. They should NEVER be used when communicating medication information. Abbreviation Intended Meaning U unit IU international unit Abbreviations for drug names QD QOD Every day Every other day OD Every day OS, OD, OU Left eye, right eye, both eyes D/C Discharge cc cubic centimetre ISMP Canada July 2006 µg microgram Symbol Intended Meaning @ at > < Problem Mistaken for “0” (zero), “4” (four), or cc. Mistaken for “IV” (intravenous) or “10” (ten). Misinterpreted because of similar abbreviations for multiple drugs; e.g., MS, MSO4 (morphine sulphate), MgSO4 (magnesium sulphate) may be confused for one another. QD and QOD have been mistaken for each other, or as ‘qid’. The Q has also been misinterpreted as “2” (two). Mistaken for “right eye” (OD = oculus dexter). Correction Use “unit”. Use “unit”. Do not abbreviate drug names. Use “daily” and “every other day”. Use “daily”. May be confused with one another. Use “left eye”, “right eye” or “both eyes”. Interpreted as “discontinue whatever medications follow” (typically discharge medications). Use “discharge”. Mistaken for “u” (units). Use “mL” or “millilitre”. Mistaken for “mg” (milligram) resulting in one thousand-fold overdose. Use “mcg”. Potential Problem Correction Mistaken for “2” (two) or “5” (five). Use “at”. Greater than Less than Mistaken for “7”(seven) or the letter “L” . Confused with each other. Use “greater than”/”more than” or “less than”/”lower than”. Dose Designation Intended Meaning Potential Problem Trailing zero X.0 mg Decimal point is overlooked resulting in 10-fold dose error. Never use a zero by itself after a decimal point. Use “X mg”. Lack of leading zero . X mg Decimal point is overlooked resulting in 10-fold dose error. Always use a zero before a decimal point. Use “0.X mg”. Correction Adapted from ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 2006 Report actual and potential medication errors to ISMP Canada via the web at https://www.ismp-canada.org/err_report.htm or by calling 1-866-54-ISMPC. ISMP Canada guarantees confidentiality of information received and respects the reporter’s wishes as to the level of detail included in publications. Institute for Safe Medication Practices Canada Institut pour l’utilisation sécuritaire des médicaments du Canada Permission is granted to reproduce material for internal communications with proper attribution. Download from: www.ismp-canada.org/dangerousabbreviations.htm Appendix 2 Providence Care Abbreviations/Acronyms/Symbols #ADM-PHI-20 Page 1 of 2 List of Error-Prone Abbreviations, Symbols, and Dose Designations Abbreviations AD, AS, AU Intended Meaning Misinterpretation Correction Right ear, left ear, each ear Mistaken as OD, OS, OU (right eye, left eye, each eye) Use “right ear”, “left ear”, or “each ear” BT Bedtime Mistaken as “BID” (twice daily) Use “bedtime” IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or “NAS” HS Half-strength Mistaken as bedtime Use “half-strength” or “bedtime” hs At bedtime, hours of sleep Mistaken as half-strength qn Nightly or at bedtime Mistaken as “qh” (every hour) Use “nightly” or “at bedtime” q.o.d. or QOD** Every other day Mistaken as “q.d.” (daily) or “q.i.d.” (four times daily) if the “o” is poorly written Use “every other day” SC, SQ, sub q Subcutaneous SC mistaken as SL (sublingual); SQ mistaken as “5 every”; the “q” in “sub q” has been mistaken as “every” (e.g. heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery) Use “subcut” or "subcutaneously” Sliding scale (insulin) or ½ (apothecary) Mistaken as “55” Spell out “sliding scale”; use “onehalf” or “½ “ ss Dose Designations and Other Information Abbreviations such as mg. or mL. with a period following the abbreviation Large doses without properly placed commas (e.g., 100000 units; 1000000 units) Intended Meaning Misinterpretation Correction The period is unnecessary and could be mistaken as the number 1 if written poorly Use mg, mL, etc. without a terminal period 100,000 units 100000 has been mistaken as 10,000 or 1,000,000 1,000,000 units 1000000 has been mistaken as 100,000 Use commas for dosing units at or above 1,000, or use words such as 100 “thousand” or 1 “million” to improve readability mg ml Symbols Intended Meaning Misinterpretation Correction For three days Mistaken as “3 doses” use “for three days” Greater than and less than Mistaken as opposite of intended; mistakenly use incorrect symbol; “<10” mistaken as “40” Use “greater than” or “less than” @ At Mistaken as “2” Use “at” & And Mistaken as “2” Use “and” + Plus or and Mistaken as “4” Use “and” ° Hour Mistaken as a zero (e.g., q2° seen as q 20) Use “hr”, “h”, or “hour” x3d > and < Subject: ABBREVIATIONS/ACRONYMS/SYMBOLS Procedure #ADM-PHI-20 Appendix 2 Page 2 of 2