Archives: Feature Stories

Mollie Cole is Director of Health System Improvement at the Health Quality Council of Alberta, and a registered nurse of many years.

As a registered nurse, I have encountered my fair share of abbreviations, symbols, and dose designations over the years. I’ve seen these used in treatment orders, prescriptions, medication administration records, care plans, clinical notes, and instructions to patients. I’m sure I was responsible for a few of these too. After all, some habits are hard to break without an occasional reminder.

That’s why, on behalf of the Health Quality Council of Alberta, I am pleased to share with you a few helpful tips and important reminders about the hazards of abbreviations, symbols, and dose designations in medical communications – and why it’s best to avoid them.

While it’s difficult to estimate the impact of this problem across Alberta, it’s not hard to find alarming studies that point to the danger of abbreviations, symbols, and dose designations in healthcare settings across the world.

One U.S. study of 30,000 medication errors, some fatal, showed five per cent were linked to abbreviations in notes.¹

As many of you in the healthcare sector already know communication shorthand commonly cause medication errors and adverse events. They can lead to the misinterpretation of instructions, especially if the language has multiple meanings or is not understood by all members of a healthcare team. And while the advent of electronic medical records and order sets have likely helped to mitigate abbreviation, symbols. and dose designations use in recent years, we know from audits that abbreviations in SMS texting are increasingly being found.

The Health Quality Council of Alberta has a mandate to promote and improve patient safety, person-centred care, and health service quality, and we’ve taken a keen interest in medication safety issues over the years such as the appropriate use of abbreviations, symbols, and dose designations.

This month, we launched a new page on our website, The Hazards of Abbreviations, Symbols, and Dose Designations, that highlights efforts healthcare providers and organizations can take to reduce the temptation to use shorthand in medical communications. This page replaces our abbreviations.hqca.ca site with a concise, updated look at this important topic.

One of the valuable resources you’ll find on our new webpage is a link to the Institute for Safe Medication Practices Canada (ISMP Canada) Do Not Use List – which is a regularly updated list of abbreviations and symbols that frequently create problems in medical communication and should never be used.

“The list is based on reports of medication errors to ISMP Canada,” said Carolyn Hoffman, CEO, ISMP Canada. “Through practitioner and consumer-lived experiences, we learn and share so that all of us can act to reduce the risk of this type of preventable harm.”

To learn more about this important topic, check out the new Hazards of Abbreviations, Symbols, and Dose Designations page.

HQCA Matters is published intermittently and presents HQCA representative perspectives on topics or issues relevant to healthcare in Alberta.

¹ BBC NEWS | Health | Medical abbreviations ‘pose risk’

In 2017, a patient died after a medication error at Vanderbilt University Medical Center in the United States. We extend our sympathies to the family who suffered this tragic loss. Many healthcare professionals watched the case carefully, as the nurse who administered the wrong medication was criminally charged.

Our view

Criminalization of a medical error diverts attention from important aspects of patient safety that support our health systems to learn and improve.

No one is more equipped to make improvements to patient safety than healthcare workers, and the patients and families they serve. Healthcare workers are at the frontline delivering and witnessing care. As a result, they are in a unique position to identify potential and actual errors. They rely on safe venues to discuss unsafe situations, and require a healthcare system that is committed to acting on their findings. When we focus on individual blame and punishment, this can create a culture of fear that shuts down transparency and fosters an environment where healthcare workers no longer feel safe to voluntarily report potential and actual errors. This ultimately makes our health systems less safe.

A just culture

Organizations with a just culture see errors as opportunities to learn and to improve the healthcare system. Healthcare workers in a just culture trust their organization and feel that staff are treated fairly when they are involved in a patient safety event, including when they make an error. Reports of errors and patient safety hazards are important sources of information about weaknesses in the system, and are used to improve patient safety.

It is vital to promoting and improving patient safety that, as healthcare leaders, we ensure our organizations have a consistent, systematic and fair approach for gathering, organizing, and interpreting information about patient safety incidents and the actions taken by those involved. This begins with a thorough assessment of an incident using a systems-based approach that supports looking beyond the contribution of the individuals involved, and considers how complex interacting elements can influence care.

Tools such as the Just Individual Assessment (JIA) support a just culture and can be used to assess individual accountability within the context of the situation, including understanding contributing system factors.

The Health Quality Council of Alberta has created recommendations on what patients and families, healthcare workers, and organizations can do to foster a just culture. Now, more than ever, we need to commit to a just culture and we invite you to join us. Please check out our just culture website and the many resources available on this important topic.

Charlene McBrien-Morrison, Chief Executive Officer

HQCA Matters is published intermittently and presents HQCA representative perspectives on topics or issues relevant to healthcare in Alberta.