What is one of the major causes of medication errors according to the Joint Commission?

The Usage of Potentially Dangerous Abbreviations and Dose Expressions is a Major Cause of Medication Errors According to the Joint Commission

According to the Joint Commission, the usage of potentially dangerous abbreviations and dose expressions is one of the major causes of medication errors. 1

Understanding Medication Errors in Healthcare

Medication errors represent a significant threat to patient safety across all healthcare settings. These errors can occur at various stages of the medication process, including:

• Prescribing
• Transcribing
• Dispensing
• Administration
• Monitoring

The Joint Commission's Focus on Abbreviations

The Joint Commission has specifically identified potentially dangerous abbreviations and dose expressions as a major contributor to medication errors for several reasons:

• Abbreviations can be misinterpreted, leading to incorrect medication administration
• Similar-looking abbreviations can cause confusion between different medications
• Dose expressions written unclearly can result in significant dosing errors

Research has shown that medication errors involving abbreviations are particularly concerning:

• Studies have found that 76.9% of hospitalized patients had one or more error-prone abbreviations used in their medication prescriptions 2
• 8.4% of medication orders contain at least one error-prone abbreviation 2
• 29.6% of these abbreviations were considered high risk for causing significant harm 2

Common Problematic Abbreviations and Expressions

The most problematic abbreviations identified include:

• "u" for units (often mistaken for "0" or "4")
• "sc" for subcutaneous (can be misinterpreted)
• Sound-alike drug names that can lead to medication interchange errors 1
• Ambiguous dose expressions
• Inappropriate use of decimal points

Impact of Abbreviation Errors

Medication errors resulting from abbreviation misinterpretation can have serious consequences:

• In pediatric settings, where weight-based dosing is common, abbreviation errors can be particularly dangerous 3
• In emergency departments, communication errors involving abbreviations can lead to critical mistakes 4
• In intensive care settings, where high-alert medications are frequently used, abbreviation errors can be life-threatening 3

Joint Commission's Initiatives to Address This Issue

The Joint Commission has taken specific steps to address this problem:

• Requiring accredited healthcare organizations to develop and maintain programs to minimize risks from look-alike or sound-alike drug names 1
• Advocating for medication error prevention strategies 5
• Recommending implementation of standardized order sets to enhance compliance with medication management standards 6

Strategies to Reduce Abbreviation-Related Errors

Healthcare organizations can implement several strategies to reduce abbreviation-related medication errors:

• Developing and enforcing a "Do Not Use" list of dangerous abbreviations
• Implementing electronic prescribing systems with built-in safety checks
• Providing ongoing education to healthcare providers about safe prescription practices
• Using clear numerical communication, such as stating numbers digit by digit 4
• Requiring read-back verification for critical medication orders 4

Conclusion

While other factors like human error, telephone orders without read-back, and technology overuse contribute to medication errors, the Joint Commission has specifically identified the usage of potentially dangerous abbreviations and dose expressions as a major cause of medication errors. Healthcare organizations must implement comprehensive strategies to address this issue and improve medication safety.