Avoiding medication errors

The use of some abbreviations, symbols  and dose designations has been identified as an underlying cause of medication errors. In this issue, we would like to remind everyone to be conscious of the abbreviations we use at the NHS. It is always more concise and safer to use long form and only use approved abbreviations and symbols.

The Institute for Safe Medication Practices Canada (ISMP) has a DO NOT USE list. This list is part of the NHS Medication Orders Policy document number 555-003-050A. It can be accessed on source•net under Policy Pharmacy section, subsection Administration. There is a hard copy in the yellow Patient Safety Binder under section 4K, Medication Safety. It can also be accessed on the ISMP website: www.ismp-canada.org.

Printing legibly is another way to avoid error and misinterpretation. All documentation should be legible. Legibility will assist to eliminate potential errors as well as enhance overall communication and increase efficiency.

The following is an example of what could be misinterpreted. This is not an NHS case – however, we can benefit from another hospital’s experience to prevent similar errors from occurring at our hospital.

The ‘u’, representing the whole word ‘units’, is easily misread as a ‘0’ (zero), leading to a 10-fold dose error. Here, the intended ‘6u’ was misinterpreted as ‘60’ and the patient received 60 units of regular (short-acting) insulin. Insulin is the most commonly-reported medication identified as causing harm in the ISMP Canada database of voluntarily reported medication errors.

Eventually, electronic documentation will be fully implemented, but in the meantime, keep the use of abbreviations to a minimum and print legibly.

Please do not hesitate to contact the NHS Patient Safety Specialist, Cindy Ko, cindy.ko@niagarahealth.on.ca, ext. 44420, if you have any questions.  «