Documentation Errors Related to Abbreviations

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The use of abbreviations in the medical field has recently become a major issue and a national concern as a cause of medication or other life-threatening errors. Medical errors have been determined to be the eighth most common cause of patient deaths in the United States (Nordenberg, 200). When dealing with medical information and a person's life, accurate and understandable written or computerized documentation is of utmost importance.

Eliminating abbreviations can reduce errors because this would require that all words be spelled out. Many abbreviations are very similar thus increasing the risk of mistaking one for another. For example, the abbreviation “U” for “Units” is commonly mistaken as a zero, four or cc (Do Not Use, 2008) . In the correct circumstances, this seemingly simple misinterpretation can be deadly for a patient.

Written policies for the use of abbreviations should be developed in all healthcare facilities to curb or eliminate errors related to misinterpreted documentation. Important contents of such policies should include information on abbreviations that cannot be used under any circumstances, specifics about who can use them, in what contexts they are allowed, and the appropriate locations for them in the patient's notes. Policies for use will help reduce errors, but in order to guarantee this, the policies should be standardized and uniform in all healthcare facilities across the nation and disciplinary action must be taken when deviations occur.

Abbreviations are acceptable when lengthy reports must be written and when the person reading and interpreting them has knowledge of their meanings. They are also acceptable when used to protect a patient's privacy. Medical abbreviations are mainly used by healthcare professionals, so people uneducated in the medical realm would not be able to interpret these sensitive reports. Abbreviations may be used by doctors, nurses, pharmacists, and any other healthcare professional who is...
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