A participating healthcare facility reported a potentially dangerous abbreviation that may cause confusion in the operating suite. A patient was scheduled for a left total hip replacement, which was abbreviated LTHR. However, the consent form presented to the patient was incorrectly written for a left total knee replacement (LTKR)—an error both the surgeon and patient detected. The visual similarity between the abbreviations LTHR and LTKR is likely the source of this problem. 

Among JCAHO’s 2004 Patient Safety Goals is the improvement of communication among caregivers, which establishes a requirement that healthcare organizations “standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.”¹ While the patient safety community typically discusses dangerous abbreviations in the context of medication errors, this case highlights the fact that abbreviations of treatments and procedures may also pose hazards to patients. 

This case illustrates the importance of reporting “near misses”, or incidents as defined in Act 13. Though this report only concerned an inaccurate consent form, and the mistake was corrected by both the surgeon and the patient, this transcription error could have occurred on the physician’s order or the OR schedule and could have resulted in a serious event. 

References

1. JCAHO Patient Safety Goals. JCAHO Web site. http://www.jcaho.org/accredited+organizations/patient+safety/index.htm. Accessed March 2, 2004.