A 67 y/o patient is found on the medicine ward one evening, cold and clammy, barely responsive. The patient's admit diagnosis was 'control of type I diabetes mellitus'. Other than the diabetes, the patient has no other pressing health problems. Their written medication orders include NPH insulin 30.0 u am and pm, regular insulin 10.0 u in the am and 3.0 u in the pm, lisinopril 20mg qam, baby aspirin 81mg qam, and simvastatin 40mg qhs. They have no allergies. After a quick assessment and check of the most recent labs and a finger stick, the resident determines the patient is very hypoglycemic. Some 50%
dextrose and glucagon quickly corrects the hypoglycemia.

How could this have happened?

SELECT  here for discussion

The problem may well have been a medication error. Not that the wrong medication was given but the wrong DOSE. The 'orders' written above in the scenario were intentionally written POORLY to illustrate the points below.  The wrong dose was probably due to the use of unapproved abbreviations - a
trailing zero AFTER the decimal? A "u" instead of units? Both? Both of these abbreviations have been reported as factors in up to 10-fold dosing errors because the person giving the dose interprets the "u" as another zero or four (4) OR the decimal point is missed. Either can cause significant problems as illustrated above.

The 2003 JCAHO national patient safety goals include the following:

1.  Improve the accuracy of patient identification.

Use at least two patient identifiers (neither to be the patient's room number) whenever taking blood samples or administering medications or blood products.

Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure and site, using active--not passive--communication techniques.

2.  Improve the effectiveness of communication among caregivers.

Implement a process for taking verbal or telephone orders that requires a verification "read-back" of the complete order by the person receiving the order.

Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.

3.  Improve the safety of using high-alert medications.

Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.

Standardize and limit the number of drug concentrations available in the organization.

4.  Eliminate wrong-site, wrong-patient, wrong-procedure surgery.

Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.

Implement a process to mark the surgical site and involve the patient in the marking process.

5.  Improve the safety of using infusion pumps.

Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization.

6.  Improve the effectiveness of clinical alarm systems.

Implement regular preventive maintenance and testing of alarm systems.

Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.

Goal #2 mandates an approved list of abbreviations and an UNAPPROVED list of abbreviations. The Wilford Hall UNAPPROVED list of abbreviations is attached below for your reference. This list will be posted on the wards, clinics, and in the medical records. These abbreviations CANNOT be used in written
orders, prescriptions, or the medical record notes/narratives. It does NOT affect short codes in the CHCS computer system. Providers are highly encouraged but not mandated to write out all drug names.

Keep in mind - this is a PATIENT SAFETY initiative and not just to create more work for the provider staff. In house, the risk management staff is monitoring compliance with these unapproved abbreviations.

WHMC UNAPPROVED ABBREVIATIONS LIST   

UNACCEPTABLE ABBREVIATIONS   

Abbreviation:  T I W              

Intended Meaning: Three times a week                

Common Error: Misinterpreted as "three times a day" or "twice a week"               

Correction:  Do not use

Abbreviation:  q.n.   

Intended Meaning:  Every night

Common Error:  HS, nightly, or every night

Abbreviation:  3d   

Intended Meaning:  For 3 days   

Common Error:  Mistaken for "3 doses"

Correction:  Use "for 3 days"

Abbreviation:  AZA

Intended Meaning:  Azathioprine

Common Error:  zidovudine

Correction:  Use the complete spelling of the drug name

Abbreviation:  ARA-A

Intended Meaning:  Vidarabine

Common Error:  cytarabine (ARA-C) 

Abbreviation:  AZT

Intended Meaning:  Zidovudine

Common Error:  azathioprine     

Abbreviation:  CPZ

Intended Meaning:  Compazine®

Common Error:  chlorproamzine       

Abbreviation:  HCT

Intended Meaning:  hydrocortisone

Common Error:  hydrochlorothiazide 

Abbreviation:  MSO4

Intended Meaning:  morphine sulfate

Common Error:  magnesium sulfate  

Abbreviation:  MTX

Intended Meaning:  methotrexate

Common Error:  mitoxantrone              

Abbreviation:  TAC

Intended Meaning:  triamcinolone

Common Error:  tetracaine, adrenalin, cocaine   

Abbreviation:  ZNSO4

Intended Meaning:  zinc sulfate

Common Error:  morphine sulfate     

Abbreviation:  Stemmed names like    Nitro - Pit 

Intended Meaning:  nitroglycerin pitocin

Common Error:  nitroprusside pitressin  

Abbreviation:  U

Intended Meaning:  unit

Common Error:  Read as 0 or 4

Correction:  Unit or Units     

Abbreviation:  ug

Intended Meaning:  Microgram

Common Error:  Mistaken for mg

Correction:  Mcg or microgram

Abbreviation:  1.0 (do not use zero after whole number)

Intended Meaning:  Signifies 1 mg

Common Error:  Misread as 10

Correction:  1 mg

Abbreviation:  .5 (do use zero with a decimal)

Intended Meaning:  Signifies 0.5 mg

Common Error:  Misread as 5

Correction:  0.5 mg

Abbreviation:  A/A

Intended Meaning:  Albuterol and Atrovent

Common Error:  Not understood

Correction:  Use complete spelling

Anecdotally, other AFB bases who have experienced recent JCAHO inspections state the JCAHO national patient safety goals have been hard hit and evaluated very closely by the inspectors.

Bottom line:

1)    DON'T use following zeros after the decimal point..
2)    DO use a zero preceding the decimal point.
3)    Spell out UNITS and do NOT use "u".
4)    Spell out all drug names and not just those listed above.