Wednesday January 30, 2008
Abbreviation Errors

Q: Which abbreviation cause the most confusion and largest numbers of error ?


A: QD = once daily

In one recent study "The Impact of Abbreviations on Patient Safety", published in The Joint Commission Journal on Quality and Patient Safety, found that "QD=Once daily" cause 43.1 % of errors out of all abbreviation errors.
From 2004 through 2006 a total of 29,974 medication errors were reported to the MEDMARX program from, attributable to abbreviation use. The top 5 confusing abbreviations were

1. "QD” (once daily) = 43.1%
2. “U” (units) = 13.1%,
3. “cc” (mL) = 12.6%,
4. “MSO4” or “MS” (morphine sulfate) = (9.7%), and
5. decimal errors = 3.7%

The total number of medication errors were 643,151, over study period (2004-2006) !


Related previous Pearls:

LASA drugs
"Five Rights"
38,000 medication errors in 4 years - only in ICUs !!
ICU satellite pharmacy Preventing intra-venous (IV) drip errors


Reference: click to get abstract / article if available

1. The Impact of Abbreviations on Patient Safety - The Joint Commission Journal on Quality and Patient Safety, September 2007 Volume 33 Number 9