Through research and reporting, these abbreviations have been found to be the source of many medical errors and patient harm. Eliminating them will increase patient quality of care and safety.60
Several examples of situations where using abbreviations that have resulted in harm are the following:
BBCNews (2008) reported that a patient who was receiving hemodialysis was prescribed 'acyclovir HD.' (The physician meant for the acyclovir to be given while on hemodialysis). The healthcare worker read this order as 'acyclovir TID' and the patient died as a result. When abbreviating medical conditions, there may be several different meanings for that abbreviation. An unfortunate woman in her 60s was seen in the emergency department for a fall she sustained, was released and the ED report was sent to her primary physician. Because there were numerous places in the chart that referred to the patient having morphine sulfate with her in the emergency department and had morphine sulfate when she fell, the patient was referred to a substance abuse program for her abuse of the drug morphine.52 Imagine this woman's horror and confusion with this referral because she actually was living with the effects of Multiple Sclerosis which caused her fall. Someone in the emergency department entered "MS" into the triage computer EHR and the system defaulted to 'morphine sulfate.'
With the cautions from The Joint Commission as well as the FDA and the Institute for Safe Medication Practices (ISMP) for healthcare workers and medication prescribers to avoid abbreviations, as much as possible, to increase patient safety; below is a list of common abbreviations that are still used when charting and writing medication orders. Exercising extreme caution when using abbreviations will maintain the quality of patient care and patient safety. Using The Joint Commission List as well as any facility list of forbidden abbreviations and allowable abbreviations will assist to maintain safe patient care.