Abbreviation Gotchas

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Abbreviation "Gotchas"

PA PSRS Patient Saf Advis 2007 Mar;4(1):10.

As discussed in previous PA-PSRS Patient Safety Advisory issues, PA-PSRS reports abound with occurrences involving misunderstanding of abbreviations. Here’s another example of an abbreviation that caused a patient to receive an unintended intervention.

A physician wrote an order for “HCT,” a common abbreviation for “hematocrit.” The staff transcribed and entered hematocrit for the morning. The physician, however, wanted the patient to receive a CT scan of the head. Because the physician used what the facility’s report identified as an unapproved abbreviation, the patient had blood drawn, but did not receive the CT scan.

If healthcare providers use facility-approved abbreviations, patients are more likely to receive interventions as intended on a timely basis.

Have you identified other abbreviations that have been open to misinterpretation or have multiple interpretations? If so, let us know by e-mailing your experience to PA-PSRS at support_papsrs@state.pa.us. PA-PSRS will publish these abbreviations in the “Abbreviation ‘Gotchas’” box in future Advisory issues.

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Abbreviation "Gotchas"

	THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS
	The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .
	ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.
	The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.