do not use medical abbreviations

Do Not Use Medical Abbreviations: Do This Instead

Do not use medical abbreviations! That might seem like a bold statement, but the experts and leading authorities back it up. We know it’s tempting —you spend hours of your day compiling notes in your EHR, typing difficult-to-spell medical terms, and filling out administrative paperwork for patients. No doubt that using an abbreviation seems like an easy solution. We’re here to tell you why it could be a risky choice to use error prone abbreviations in your medical practice. 

Here are some of the major downfalls to using medical abbreviations: 

  • Increased risk of errors and miscommunication. For example, IU could be confused with IV. Or MSO4 (morphine sulfate) might be confused with MgSO4 (magnesium sulfate). Those miscommunications can put your patients and your medical license at risk. One study found that out of 103 critical incidents, 56% were caused by dangerous abbreviations.
  • Many abbreviations are restricted by hospitals and other employers. In light of this, it’s probably best not to fall into the habit of using abbreviations in case you move to another practice where a particular abbreviation you use is disallowed.
  • From a medicolegal perspective, you want your notes to be decipherable by a lay jury in case of litigation or other legal action. Abbreviations make your notes more difficult to comprehend.

We know many in the medical field spend hours per day on paperwork, and many practitioners suffer from debilitating RSI pain. Thankfully, there is an alternative to error prone abbreviations: TextExpander, which is a powerful dotphrase tool that you can use inside or outside of your EHR. Set up Snippets for your common abbreviations and set them to expand into their full terms. For example, you could create a Snippet so when you type MgSO4, it expands to magnesium sulfate.

TextExpander offers you the time-savings of abbreviations without the risks. It’s trusted by practitioners around the world, like Dr. Melanie Hsu of the Children’s Health Council and Dr. Jeremy Sharp of the Colorado Center for Assessment & Counseling.

See how TextExpander works

intravenous

magnesium sulfate

International Unit

This article will cover:

Why are abbreviations used in healthcare?

Despite their drawbacks, many in the medical field are compelled to use abbreviations due to long hours recording documentation, fast-paced work environments, long and difficult-to-spell medical terms, and debilitating repetitve stress injuries.

Physicians spend nearly 40% of their workday in their EHR, which is time taken away from seeing patients. Additionally, practitioners often work in fast-paced and high-pressure environments, contributing to more than 90% of doctors experiencing burnout. Despite that, documentation must be thorough and comprehensive in order to maintain continuity of care, maximize insurance reimbursements and mitigate legal liability.

Medical record keeping not only takes away from time with patients, it can have a serious impact on your medical career. Dr. Melanie Hsu of the Children’s Health Council told us how her and her team have suffered from repetitive stress injuries (RSI) due to typing out long reports about their patients.

Not able to play the video? Click here to watch the video

“As an evaluator, we often have to write 30, 40, or 50 pages of reports, and so my evaluation team was often known around the building because we had wrist guards, wrist braces, and pain patches,” Hsu says.

While the drawbacks of medical abbreviations are overwhelming, so are the reasons they are used. Neil M. Davis, PharmD, MS, FASHP notes that while “a high price can be paid for their use,” abbreviations are difficult for organizations to ban outright: “Not allowing the use of any abbreviations would be an exceedingly difficult edict to introduce and enforce,” he writes for the Institute for Safe Medication Practices.

“Yes, abbreviations are so ingrained in medicine and medical terminology, that even when physicians intentionally try to avoid abbreviations, they still manage to slip in. Despite the potential downfall, abbreviations allow us to save time in both written and verbal communication,” says Dr. Jared Ross of Emergency Medical Services, Education, & Consulting, LLC.

TextExpander offers an alternative to medical abbreviations: you can type a short abbreviation and it expands into the full term or phrase, so you save time typing while reducing the risk of miscommunications. Learn more about how TextExpander can help your healthcare team.

The Do Not Use List of medical abbreviations

The Joint Commission publishes a list of abbreviations that the organizations it accredits are not to use, and many healthcare organizations build from this list. Here are common items you’ll find on Do Not Use abbreviation lists:

#AbbreviationMistakeCorrect Form
1U, uMistaken as zero, four, or ‘cc’Write ‘unit’
2IUMistaken as IV or 10Use ‘International Unit’
3Q.D., QD, q.d., qdMistaken as each otherWrite ‘daily’
4Q.O.D., QOD, q.o.d, qodMistaken as QD (daily) or QID (four times daily)Write ‘every other day’
5Trailing zero (X.0 mg)Decimal point is missedDo not use. Write ‘X mg’ or use zero before a decimal point for doses less than one (0.X mg)
6Lack of leading zero (.X mg)Mistaken as X mgWrite ‘0.X mg’
7MS, MSO4 and MgSO4Can mean morphine sulfate or magnesium sulfateWrite ‘morphine sulfate’ or ‘magnesium sulfate’
8> (greater than), < (less than)Mistaken as the opposite of each other, or as the number 7 or letter LWrite ‘greater than’ or ‘less than’
9Abbreviations for drug namesMistaken for one another or misinterpretedWrite the full drug names

Why are medical abbreviations placed on the Do Not Use list?

While medical abbreviations are discouraged across the board, certain abbreviations and symbols can be especially dangerous because they resemble other abbreviations and symbols and thus are easily misinterpreted.

A study from the Canadian Journal of Hospital Pharmacy reports:

The link between the use of dangerous abbreviations and critical incidents was shown by the Commonwealth of Pennsylvania Patient Safety Authority, which found, upon review of 103 critical incidents, that 56% involved the use of dangerous abbreviations and dose expressions (as reported during a teleconference entitled “Alphabet Soup: Hazardous to Your Health!” [sponsored by the Institute for Safe Medication Practices, February 4, 2005]).

Reasons an error prone medical abbreviation may be specifically forbidden:

  1. Risk of misinterpretation: Many abbreviations can be easily misunderstood or mistaken for other similar abbreviations, leading to incorrect patient treatments. For instance, “U” (for units) can be mistaken for “0” (zero), causing an overdose or underdose if misinterpreted.
  2. Similarity to other abbreviations or symbols: Some abbreviations are visually similar to others or can be confused with common symbols, which increases the risk of miscommunication. For example, “IU” (International Units) can be mistaken for “IV” (intravenous) or the number “10”.
  3. Lack of standardization: While many abbreviations are widely recognized, there’s a lack of universal standardization across different healthcare facilities and regions. This lack of consistency can lead to confusion, especially for healthcare professionals who may work in various settings or with diverse patient populations.
  4. Errors in transcription: When handwritten, some abbreviations can be difficult to read or easily misinterpreted by other healthcare professionals, pharmacists, or staff, leading to errors in medication ordering, dispensing, or administration.
  5. Variability in interpretation: Some abbreviations have multiple meanings, and the context may not always clearly indicate which interpretation is correct. For example, “MS” could mean morphine sulfate or magnesium sulfate, two very different medications with different uses and potential risks.

“There are other measures for dosing errors too that need to be done. For example, including a leading zero when it’s a decimal less than 1 (0.5) and not writing 1 as 1.0 (which someone may see as 10),” says Joanna Lewis, PharmD, MBA of Baptist Health and the American Society of Health-System Pharmacists.

What are the concerns about using medical abbreviations?

The chief concern when using medical abbreviations is the possibility that they may be misinterpreted by practitioners, leading to medical errors like a drug misdosage.

“Overall, it appears that the three most common errors due to medical abbreviations were errors in prescribing, improper dose/quantity, and incorrect preparation of the medication,” says an article by Rayhan A. Tariq of South Central Regional Medical Center and Sandeep Sharma of Mery Fitzgerald Hospital.

Not only can abbreviations lead to medical errors, they can cause a delay of treatment for patients, which presents its own risks.

A study from the Canadian Journal of Hospital Pharmacy says, “Unfortunately, the use of those dangerous medical abbreviations can present a dilemma for medical providers, who must either guess their meaning or risk delaying treatment. The study authors  say, “Nursing and pharmacy staff are often put in the difficult and risky position of processing orders that contain dangerous abbreviations and dose designations. The alternative to processing such orders is either clarifying each order or refusing to process the orders, both of which also put patients at risk.”

“I recall an instance where the abbreviation BPD led to a misunderstanding between healthcare professionals. In psychology, BPD commonly refers to Borderline Personality Disorder, but in other medical contexts, it might stand for Bipolar Disorder or even Bronchopulmonary Dysplasia in neonatal care,” says Dr. Nick Bach, CEO of Louisville Grace Psychological.

Abbreviations introduce a certain degree of ambiguity to patient notes, which is unacceptable in modern medical practice. “Abbreviations can have more than one contradictory or ambiguous definition, which can result in errors in communication due to misunderstanding or misinterpretation. Modern patient care is multidisciplinary, so there should be no room for ambiguity in patient medical records,” says Dineth C Jayatilake and Samson O Oyibo.

“Early in my dental practice, I encountered confusion due to using the abbreviation *MOD* in a patient’s records. In dental terms, *MOD* typically refers to a restorative dental procedure involving the Mesial, Occlusal, and Distal surfaces of a tooth. However, there was a misunderstanding during a case discussion with a medical professional unfamiliar with dental abbreviations. The medical colleague interpreted *MOD* as an abbreviation for *Mode,* leading to confusion regarding the treatment plan,” says dentist Jennifer Silver, owner at Macleod Trail Dental Clinic.

Finally, avoiding abbreviations makes your notes more readable. Per Thomas G. Gutheil, MD, your medical notes may be read by:

  • Other members of the treatment team
  • On-call physicians
  • Emergency physicians
  • Colleagues covering your practice when you’re on vacation or off shift
  • Utilization reviewers
  • Members of professional standards review organization (PSRO) committees
  • Insurers
  • Quality assurance reviewers
  • A plaintiff’s attorney or the patient themselves, in a worst-case scenario

That last point is critical. In the case of legal action, it is essential that your clinical decisions are clear to a jury of laypersons. Otherwise, an attorney could portray you as irresponsible.

“Thus, if the patient does in fact suffer an ill effect from medication, it is all too easy for a plaintiff’s attorney to portray the physician as having cavalierly prescribed this dangerous substance to the patient; however, if the physician has noted that the goal of this medication is to prevent or improve a condition, the sense of a balanced and reasoned decision becomes much clearer to a lay audience,” Gutheil says.

However, good documentation can protect you. “Clinical judgment is itself the polar opposite of negligence, one of the critical elements of malpractice,” Gutheil adds.

Ensuring that your documentation is clear and professional paints you and your decision-making in the best light and helps the audience feel included.

“Abbreviations are mentally taxing on a reader and can incidentally alienate an audience. By simply replacing them with the words that they stand for, we greatly improve our communication. The field of psychological science is moving toward increased openness in scientific practices. While we are at it, let us consider also making our writing more open and easily accessible,“ says the Association for Psychological Science.

Is it best practice to use medication abbreviations?

No. Medical experts are in unanimous agreement that error prone medical abbreviations are not worth the risks. “The use of abbreviations in medication orders has been identified as an underlying cause of serious, even fatal medication errors,” says the Canadian Journal of Hospital Pharmacy.

“I make a conscious effort to avoid abbreviations in my medical documentation. The primary reason for this is the importance of clear, unambiguous communication in patient safety,” says Susan Williams, RN of Retirement Being.

“A shorthand, after all, is a useful tool – practical, time-saving, expedient. But here’s the paradox of our abbreviations in the medical field: they’re useful, but they also contain a bit of something that, at its worst, obscures clarity and fosters problems for patient care. So the principle that we’re most taught first is that the patient’s best interests must always come first, even to the extent of painstaking word choice in the notes we write,” says Dr. Kevin Huffman of AmBari Nutrition.

Avoid risky medical abbreviations, and instead choose TextExpander to save time. Medical practitioners worldwide trust TextExpander to save time on documentation, reduce RSI pain, and lessen the chances of medical errors.