Educational Intervention to Reduce Frequency of Use of Restricted Abbreviations in a Community Health Center

Abstract

Background:

Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) patient safety goals recognize that misuse of many common medical abbreviations correlates directly with medication errors. An institution-specific educational intervention may facilitate appropriate use of abbreviations to improve communication.

Objective:

To estimate the frequency of use of JCAHO-restricted abbreviations in prescriptions received at an outpatient pharmacy and determine whether an educational intervention on proper abbreviations decreases the rate of use of restricted abbreviations.

Methods:

Prescription records from an outpatient pharmacy of an urban community health center were reviewed during a 3 week interval to determine the baseline rate of inappropriate abbreviation use. Following an educational intervention, prescription records were prospectively reviewed for a 3 week interval to compare the frequency of inappropriate abbreviation use.

Results:

Inappropriate abbreviation use occurred at a rate of 25.8% (214/829) in the preintervention group and 18.3% (169/922) in the postintervention group (p < 0.001). The most commonly misused abbreviation was QD, representing 98.5% and 98.2% of the misused abbreviations before and after the intervention, respectively. Compared with the preintervention period, the frequency of overall abbreviation misuse (25.8% vs 18.3%; p < 0.001) and use of QD (62.4% vs 50.9%; p = 0.001) were decreased after the educational intervention.

Conclusions:

There is a high frequency of use of the abbreviation QD within this institution. While a brief educational intervention decreased the frequency of inappropriate abbreviation use, the rate of abbreviation misuse remained unacceptably high. A system-wide educational effort and/or enforcement approach may be needed to target inappropriate abbreviation use.