Prohibited Abbreviations in Electronic Medical Records

* Department of Pharmacy, Georgia Regents Children’s Hospital of Georgia, Augusta, Georgia.

Kelley Norris

* Department of Pharmacy, Georgia Regents Children’s Hospital of Georgia, Augusta, Georgia.

Corresponding author: Cady Ploessl, PharmD, BCPS, 1120 15th Street, Augusta, GA 30912-2450; phone: 319-331-3565; fax: 706-721-3994; e-mail: moc.liamg@lsseolp.ydac

The Joint Commission provides guidance to practitioners on safe medication practices through its “Do Not Use” list of abbreviations. In this list, clinicians are encouraged to avoid the use of prohibited abbreviations in patient history and physicals, progress notes, discharge summaries, and medication orders. Avoidance of prohibited abbreviations helps to reduce medication errors that can lead to patient harm. The use of electronic medical records (EMRs) has decreased medication errors caused by illegible handwriting by health care providers, but medication errors can be increased if prohibited abbreviations are used in these communications. Electronic communication must follow previous standards for safe medication practices.

Pharmacists play an integral role on an institutional performance improvement committee through their knowledge of safe mediation practices. Our institution performed a rapid-cycle improvement initiative targeting health care provider’s use of institutionally recognized prohibited abbreviations in EMRs. In parallel, the impact of pharmacy on a quality improvement initiative was assessed. Pharmacy led education regarding the avoidance of prohibited abbreviations in free-text EMR documentation and evaluated compliance with our institution’s safe medication practice policy, which includes an expanded prohibited abbreviation list.

Eighty patient charts were randomly selected for inclusion in this 10-week evaluation. The pre-education audit found 295 prohibited abbreviations in 40 EMRs, with medication abbreviations being the most common prohibited abbreviation (78%) ( Table 1 ). Education interventions to reach practitioners were performed by pharmacy personnel, including publishing prohibited abbreviations in physician workrooms, nursing work areas, and morning resident and faculty meetings; distributing data collection results and educational material to physician department chairs; recruiting unit-based clinical pharmacists to educate medical teams; and participating in the nursing skills fair. The post education audit found that pharmacist-led education resulted in a 68% reduction of prohibited abbreviations in 40 EMRs.

Table 1.

Frequency of prohibited abbreviation use in electronic medical records (EMRs) before and after educational intervention (N = 40)

As advances in technology are integrated into health care, communication is increased between health care providers. Providers must continue to avoid using prohibited abbreviations to ensure patient safety. Our performance improvement initiative highlights the impact pharmacists may have on an institution’s achievement of National Patient Safety Goals and encourages pharmacists to be at the forefront of safe medication practices at their institution.

Acknowledgments

The authors report no actual or potential conflict of interest. No financial support was received.

This material was presented at the University HealthSystem Consortium Pharmacy Council Meeting; December 7, 2013; Orlando, Florida.