Incorrect interpretation of drug abbreviation’s can lead to serious harm for patients. Consider the following: At 7:00 AM, Jane, a registered nurse enters the details for Mary, the last of her five patients as she completes a 12-hour shift. As the day begins, Ann is checking on patients and reviewing their charts. She is confused by an abbreviation “MTX” for a medication given to Mary at 4:30 AM. It can be interpreted as methotrexate (used for rheumatoid arthritis) or mitoxantrone (a cancer drug).
Historically, bad doctor script, poor processes and inconsistent standardization contributed to prescription errors. Today, most prescriptions are submitted electronically (e-prescribing), electronic medical records (EMRs), and by computerized physician order entry (CPOE). (L. Anderson 2016) The use of technology has reduced “chicken scratch” interpretation issues and overall prescription errors. However, discrepancies between structured and free-text fields in electronic records and prescriptions are common and can lead to serious medical errors (L. Anderson 2016).
Healthcare data is essential to treatment, decision making, operational maintenance and risk management. Today the amount of data available can be daunting and difficult to select the “right” measures. Although the selection of a measure that does not support the organization in achieving its objectives is a risk and data integrity and human input is an important variable in that risk calculation.
Above, we exemplified how one abbreviation can mean two distinct drugs creating a potentially dangerous outcome for the patient which has implication in data reporting. For example, using free form fields, Aspirin has three standard abbreviations ASP, ASA and APC, but staff also might use, AP, asp, ap, as, apn, APN or other combinations. The system will record each entry as a separate attribute, all of which mean aspirin. When a query is run asking how many aspirins were distributed in a period the results will underestimate the actual use. The query is only as good as the supporting syntax. To complicate matters the acronym, ASP, can also mean Application Service Provider, Active Server Page or other things. Not only are there different combinations, there are also different meanings for the same abbreviations.
Syntax errors are one of many opportunities for data integrity failures which compounds and magnifies risk at an exponential rate. It is not hard to see that data pulled from a non-standardized system could generate misleading information which in turn would have an adverse impact in the decision process.
Numbers can also lead to errors in drug administration. A patient was prescribed “furosemide 40 mg Q.D.” (40 mg daily) and this was misinterpreted as “QID” (40 mg four times a day) resulting in a fatal medical error. Another common error involves drug dosage units. Dosages should always be spelled out, because micrograms abbreviation “µg” (micrograms) can be misread as “mg” (milligrams), which results in a 1000-fold overdose (L. Anderson 2016)
ENTERPRISE RISK MANAGEMENT
Enterprise Risk Management (ERM) (Office 2016) helps organizations address critical operational objectives, by identifying the “gaps” and potential problem areas with the risk of failing to meet objectives. A combination of excessive risks in complex systems can perpetuate a sentinel event because of cascading risks.
Reducing risks in a sequential process diminishes uncertainty across the process stream thereby decreasing the likelihood of a sentinel event. It is essential to utilize a strategic approach, assessing risk based on set objectives and applying appropriate analysis and treatments to reduce uncertainty.
These examples may seem simplified, but there are thousands of patients and thousands of drugs which creates hundreds of thousands of variants. Standardizing one element in the equation greatly reduces variability and uncertainty. Identification of gaps and subsequent risk treatment is consistent with the Triple AIM improving patient outcomes, improving the health of populations, and reducing per capita costs of health care.
Incorrect decision made from bad syntax can affect the quality of care, have a negative impact on population health. Waste and rework from bad decision drive costs into the system. The expense of addressing risk is fractional compared to when these errors affect a patient.
Bio:
Steven C. Bradt has 20+ years’ experience working with risk and continuous improvement efforts (Lean, Six Sigma, Leadership, Change, TQM) receiving his primary Continuous Improvement education from Johnson Controls (JCI) Toyota Business Unit (TBU) and Toyota US, UK and Australia and his Six Sigma education from the Six Sigma Academy (Mikel Harry). Steven has supported and worked internationally for Retail. Software, three governments, Office of the Secretary of the Airforce (Chief Management Office), and numerous healthcare organizations in developing sustainable CPI and risk strategy. Steven is currently pursuing his Master of Health Administration Milken Institute School of Public Health at The George Washington University and he was an Honorary Fellow at Manchester Business School.
- Anderson, P. C. r. (2016). “Medical Abbreviations on Pharmacy Prescriptions.” from https://www.drugs.com/article/prescription-abbreviations.html.
Office, U. S. G. A. (2016). ENTERPRISE RISK MANAGEMENT “Selected Agencies’ Experiences Illustrate Good Practices in Managing Risk. Washington DC.