Avoiding Potential Medication Errors Associated with Non-intuitive Medication Abbreviations

ABSTRACT Background: Pharmaceutical companies use a variety of abbreviations to denote short- and long-acting medications. Errors involving the administration of these medications are frequently reported. Objectives: To evaluate comprehension rates for abbreviations used to denote short- and long-acting medications and to evaluate whether changes to medication labels could reduce potential errors in the selection and administration of medications. Methods: In phase 1 of the study, nursing staff were asked to define 4 abbreviations and then to categorize them by release rate. In phase 2, a simulation exercise, nursing staff were asked if it would be appropriate to administer a medication illustrated in a photograph (oxycodone CR 5-mg blister pack) on the basis of information highlighted in a screen shot of an electronic medication administration record (order for oxycodone 5 mg). Three different presentations were used to identify the medication in the medication administration record and on the drug label. Results: In phase 1, 10 (28%) of 36 nursing staff members knew what all 4 abbreviations meant, and 14 (39%) correctly classified all 4 abbreviations as indicating a short- or a long-acting medication. In the simulation exercise (phase 2), labelling changes reduced the likelihood of a potential medication administration error. Conclusions: Most abbreviations used to indicate short- versus longacting medications were not correctly understood by study participants. Of more concern was the incorrect interpretation of some abbreviations as indicating the opposite release rate (e.g., “ER” interpreted as meaning “emergency release”, rather than “extended release”, with incorrect classification as a short-acting medication). This evaluation highlighted the potential consequences of using non-intuitive abbreviations to differentiate high-risk medications having different release rates. RESUME Contexte : Les societes pharmaceutiques utilisent une panoplie d’abreviations pour designer leurs medicaments a action breve ou prolongee. Or, on signale des erreurs frequentes d’administration de ces medicaments. Objectifs : Evaluer le taux de comprehension des abreviations utilisees pour designer les medicaments a action breve et a action prolongee et si des changements aux etiquettes de ces medicaments pourraient reduire les erreurs potentielles dans le choix et l’administration de ceux-ci. Methodes : Dans la 1re phase de l’etude, on a demande au personnel infirmier de definir quatre abreviations et de les classer par vitesse de liberation. Dans la 2e phase, un exercice de simulation, on a demande au personnel infirmier s’il serait approprie d’administrer le medicament qu’on leur presentait sur une photo (oxycodone CR [ controlled release , c.-a-d. a liberation controlee] a 5 mg en plaquettes alveolees) en tenant compte de l’information surlignee dans une capture d’ecran d’un registre electronique d’administration des medicaments (prescription d’oxycodone 5 mg). Trois presentations differentes ont ete utilisees pour designer le medicament dans le registre d’administration des medicaments et sur l’etiquette du medicament. Resultats : Dans la 1re phase de l’etude, 10 (28 %) des 36 membres du personnel infirmier connaissaient la signification des quatre abreviations et 14 (39 %) les ont correctement classees dans la categorie action breve ou action prolongee. Dans l’exercice de simulation (2e phase), les changements a l’etiquette ont reduit la possibilite d’une erreur potentielle d’administration du medicament. Conclusions : La plupart des abreviations utilisees pour designer les medicaments a action breve par rapport a ceux a action prolongee n’etaient pas bien comprises du personnel infirmier. Mais plus inquietante etait l’interpretation erronee de certaines abreviations a l’inverse de leur vitesse de liberation (p. ex., ER interpretee comme etant emergency release (c.-a-d. a liberation d’urgence) plutot que extended release (c.-a-d. a liberation prolongee) et incorrectement classee comme un medicament a action breve). Cette evaluation souligne les consequences potentielles de l’utilisation d’abreviations non intuitives pour differencier les medicaments a risque eleve ayant des vitesses de liberation differentes.