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Standardize abbreviations to meet accreditor requirements

Ambulatory Safety Monitor, April 14, 2005

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Both the JCAHO and the AAAHC weighed in on the use of abbreviations this year. The JCAHO made standardizing a list of prohibited abbreviations a requirement in its National Patient Safety Goals, and the AAAHC added it to its standards revisions.

Ambulatory surgery centers (ASC) must pay close attention to their use of abbreviations to abide by their accreditors' requirements and to improve their patient safety efforts.

What the JCAHO expects

During its abbreviation summit in November 2004, the JCAHO questioned whether there should be a universal "do not use" list and, if so, what should or should not be on it.

Although the topic remains under review, the JCAHO said it wants organizations to follow the requirements of 2.b in 2005 National Patient Safety Goal #2, which requires facilities to standardize abbreviations, acronyms, and symbols used throughout the organization, and to include a list of those that may not be used.

The summit's participants concluded that this goal applies to: all orders, not just medication orders; all medication-related documentation, such as progress notes; handwritten documentation; preprinted forms.

The goal does not include computer-generated forms or displays at this time. The JCAHO expects further evaluation on this subject.

The problem areas stem from behavioral adjustments, said Richard J. Croteau, MD, executive director for strategic initiatives at the JCAHO, during a recent audioconference. When you are introducing your "do not use" list or any changes in your facility, practice consistency throughout the organization and offer adequate education to all staff affected by the changes.

For example, give providers a cheat sheet of acceptable and unacceptable abbreviations to carry or post inside patient charts or on preprinted forms. Repetition helps people to retain information.

What the AAAHC expects

AAAHC standard 6.G received an addition regarding abbreviations for 2005. The standard now states that "any abbreviations and dose designations must be standardized according to a list approved by the organization."

Create a policy for your approved and unapproved abbreviations and educate your staff about it. Although it's a challenge to keep staff consistent with abbreviation use in ASCs, both the clinical record and the provider move across several departments or facilities.

For example, one physician may write an abbreviation in a clinical record that will go to another facility and be read by a different physician. If the facilities are under different authorities, the risk of error increases.

If the facilities are under the same umbrella organization, consistency should be attainable through proper education.

To avoid confusion, interview staff at facilities your patients often visit to see what approved and unapproved abbreviations they use and try to streamline them.

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