How error-prone terms can lead to medication errors

How error-prone terms can lead to medication errorsMedication errors account for a good percentage of medical malpractice cases and the fact of the matter is that they are far too common. Whether a doctor fails to identify potentially harmful drug interactions or a patient is given the wrong drug or dosage, error-prone terms can lead to medication errors and people can suffer enormously as a result. Sadly, some of these mistakes are made simply because of someone misinterpreting or misreading medical information.

The Institute for Safe Medication Practices (ISMB) has an extensive list of the most error-prone abbreviations, dose designations and symbols that contribute to medication errors. Those that appear on the list are no longer supposed to be used in the field of medicine, but knowing what some of them are might be a good indicator of just how easily and often these mistakes are made.

Some examples of common errors include:

  • HS and hs: These abbreviations mean “half-strength” and “at bedtime” respectively and can easily be mixed up;
  • q1d and q.i.d.: These abbreviations mean “daily” and “four times daily” respectively. If misread, a person could suffer an overdose;
  • Decimals and zeroes: In dosing, 1.0 mg can be misread as 10 mg or .5 mg as 5 mg;
  • Drug abbreviations: Shortening something like hydrochloric acid to “HCI” could be misinterpreted as potassium chloride if the H is mistaken for a K.

These are just a few of the very common errors that can be made in prescribing, filling and using medications. Even though many prescriptions won’t cause serious harm to patients, sometimes the smallest mistake can have serious consequences when it comes to medication. One mistyped or misread number or letter could prove to be detrimental to a person’s health.

In addition to the ISMB’s error-prone abbreviations list, the Federal government and many State governments are making big investments in technology to improve patient safety like electronic health records and e-prescriptions.

Patients can do a few things as well, to avoid medication errors. They should be clear on the medications they are prescribed and the instructions when they leave the doctor’s office.  When they pick up the prescription they should check to make sure the drug name and instructions match their doctor told them. When refilling a prescription, patients should double check the medication, it may have been refilled with a generic version of the drug and might be a different shape and/or color than the previous pills. Finally, if there are any doubts, patients should ask their pharmacist to make sure they are receiving the medication prescribed by their doctor.

Sources:

E-prescribing systems within electronic health records reduce ambulatory prescribing errors in community-based practices: Research Activities, February 2012, No. 378. February 2012. Agency for Healthcare Research and Quality, Rockville, MD.

The Impact of Abbreviations on Patient Safety: The Joint Commission Journal on Quality and Patient Safety. September 2007.


Medication Errors

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