Identifying Continued Use of Error Prone Abbreviations

Submitter Information

Author: Gail Armstrong, ND, RN
Title: Assistant Professor
Institution: University of Colorado Denver College of Nursing

Competency Category(s)

Learner Level(s)
Pre-Licensure ADN/Diploma, Pre-Licensure BSN

Learner Setting(s)
Clinical Setting

Strategy Type
Case Studies

Learning Objectives

  • Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as work-arounds, and dangerous abbreviations).
  • Demonstrate effective use of technology and standardized practices that support safety and quality.
  • Value the contributions of standardization/reliability to safety.
  • Participate appropriately in analyzing errors and designing system improvements.
  • Value vigilance and monitoring (even of own performance of care activities) by patients, families and other members of the health care team.
  • Value relationship between national safety campaigns and implementation in local practices and practice settings.

Strategy Overview

This clinical learning activity is appropriate for early clinical courses in a pre-licensure curriculum. In Colorado, where this strategy was developed, there is a long term care rotation in Fundamentals of Nursing. This learning activity is used in that rotation. The activity would also fit well for a junior Med/Surg clinical rotation.
Before class, I assign the students the following homework:
Go to the website for The Institute for Safe Medication Practices ( Under the “Medication Safety Tools and Resources,” print out the “Error Prone Abbreviation List.” Review the list and be sure that you are familiar with the abbreviations to avoid, the misinterpretations that have been reported, and the potential danger in their continued use.
During class I lead a discussion on ISMP’s Error Prone Abbreviation List. We talk about the evolution of this list, the overlap of ISMP’s work with The Joint Commission’s National Patient Safety Goal that focused on abbreviations to avoid. I ensure during this class that all students have printed off the list and have a strong working knowledge of the list’s implementation in the practice setting. During this class I also review The Health Insurance Portability and Privacy Act (HIPPA), and have the students review the nature of deidentified patient data.
The students then receive this assignment for a day at their clinical rotation:
During your clinical rotation, as you review patient charts to prepare for patient care, keep a running list of all of the “error prone abbreviations” that you come across. Do not include any patient identifying information in your notes – all of your notes must be deidentified patient data. Keep record of the following information: • Copy down the error prone abbreviation in the context of the order or documentation, as it is written • If the error prone abbreviation is repeated in a set of orders or documentation, keep track of its recurrence. • Keep track of recurrence of error prone abbreviations by provider (e.g. LIP #1, LIP #2, RN #1, RN#2 etc…)
Type up the inclusive list of error prone abbreviations that you found in charts. Create a two column table where for every use of an error prone abbreviation, you write how the order or documentation should have been correctly written, without the error prone abbreviation. See the example below:
Error Prone Abbreviation as found in chart Correction for Order “give 10u regular insulin now” Give 10 units of regular insulin now “5,000u of heparin SC qd” 5,000 units of heparin subcutaneously daily
After you have typed up your table, choose 3 examples of incorrectly written orders or incorrect documentatoin, and explicate what might have been a patient outcome if each of these 3 error prone abbreviations had been misinterpreted. What might be the dosage calculation error? Would the error result in underdosing a patient, or potentially overdosing a patient? Look up the normal limits for that medication and infer possible patient outcomes. What are other ways that patient care might be compromised by the misinterpretation of these 3 orders or pieces of documentation?
Please conclude this write-up with a summary of what you learned from this data mining exercise. Were there any patterns to what you found (e.g. recurring offenders, recurring circumstances around the incorrect documentation, etc…). How will this exercise impact your nursing practice (please stretch for an insight beyond, “I will not use error prone abbreviations.”)

Submitted Materials

Additional Materials

Evaluation Description

Possible total points: 100
List of error prone abbreviations from charts, without any patient identifiers: 10%
Table listing incorrect documentation, with correct documentation 10%
Clinical implications of incorrect documentation – example #1 20%
Clinical implications of incorrect documentation – example #2 20%
Clinical implications of incorrect documentation – example #3 20%
What was learned from this exercise/impact on practice 20%