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Patient safety and promotion of zero medication errors are common goals in every healthcare institution. One of the policies that answers the said goals is the policy made by JCAHO that was made effective on January 2004. The said guideline is the "do not" use abbreviation. JCAHO (Joint Commission on Accreditation of Healthcare Organizations) provided institutions with a list of dangerous abbreviations that should be avoided in clinical documentation. Examples of which are "U" which is used for units, Q.D. and Q.O.D that are commonly interchanged, MgSO4 and MS that are also confused for one another.

Moreover, ISMP (Institute for Safe Medication Practice) also promotes the consistent application of not using specified abbreviations to prevent errors. The said policy recommends not using abbreviations, symbols and acronyms in medical communication. Examples of which are: D/C for discharge which is also interpreted as discontinue, T.I.W which means three times a week but is sometimes interpreted as three times a day.

The said policy was made because of the errors that the abbreviations cause. According to John P. Santell, MS, RPh, dangerous abbreviations and symbols compromise patient care and place health team members to commit medication errors. Studies have shown that the use of abbreviations/ acronyms or symbols in medical communication had been one of the reasons of medication errors. Commonly, abbreviations are misinterpreted that leads to unsafe health practice. It had been recorded that about 19,000 errors from 498 facilities stated that abbreviations are the cause of the error. (USP Center for the Advancement of Patient Safety. U.S. Pharmacopeia's MEDMAR )

Therefore, these abbreviations should never be used in communicating with other health team members such as prescriptions, nurse's notes, doctor's order, medication treatment records and medication cards. Consequently, the use of the said policy is of great advantage to the healthcare system. First and foremost, it ensures patient safety because of the prevention of errors. Secondly, it promotes safe and efficient communication between the health care team.

However, aside from the available policy from the JCAHO, an extensive written policy regarding the said issue should be researched and accomplished. Corresponding sanctions should also be created if the policy is not followed. An extensive policy will result to better outcomes. Furthermore, the "do not use abbreviation "policy is not enough to prevent medication errors. Along with the use of the policy, proper information dissemination and adequate education of the health care members should be enhanced. I strongly believe that posting the list of the said abbreviations in nursing units, bulletin boards and the internet is not enough to fully stop errors. Provision of teachings and ensuring that all medical staff are fully oriented and are following the policy are ways to prevent errors due to usage of abbreviations. Also, regular evaluation of the adherence to the policy should also be done. Memo should be given to medical members not following the policy. Strict application of the policy should be implemented so as to prevent lapses in the adherence to the policy.

In conclusion, JCAHO, ISMP, other private organizations and hospitals have taken the big step to reduce errors caused by the use of abbreviations, symbols and acronyms. However, we can never be too safe. It is important that proper education be given to all the health care members and frequent evaluation be done. Regular seminars should also be conducted for medical, nursing, and pharmacy staff on the potential for misinterpretation whenever a new drug product is added to the facility's formulary. Additionally, it is also a responsibility of the health team to strictly adhere to the policy. Since the policy was started, it is also recommended that a more extensive and an updated written policy be carried out.


- AORN Guidance Statement: "Do-Not-Use" Abbreviations, Acronyms, Dosage Designations, and Symbols. , Volume 84 , Issue 3 , Pages 489 – 492

- Beware of Abbreviations: A 'Do Not Use List' Can Help Avoid Problems by John P. Santell, MS, RPh USP Center for the Advancement of Patient Safety

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