Education Campaign Launched to Combat Medication Errors

WASHINGTON — The Food and Drug Administration and the Institute for Safe Medication Practices have launched a national education campaign aimed at health care professionals and pharmaceutical companies with the goal of reducing the number of medical mistakes caused by confusing medical abbreviations.

Each year, more than 7,000 deaths occur in the United States as a result of medication errors, and many of these are caused by the misinterpretation of medical abbreviations, Carol Holquist, director of the Division of Medication Errors and Technical Support at the FDA's Center for Drug Evaluation and Research, said at a press conference.

When a “U” looks like a zero, a patient may receive a 10-fold overdose—40 units of insulin rather than 4 units, for example. Dosage designations represent another danger zone: A misplaced or deleted decimal point can turn 1.0 mg into 10 mg, or 0.1 mg into 1 mg.

Yet the ongoing use of error-prone abbreviations, symbols, and dosage designations has not been addressed as the systemic problem that it is, said Michael Cohen, Sc.D., president of the Institute for Safe Medication Practices (ISMP).

The use of electronic prescribing information doesn't solve the problem, Dr. Cohen noted. “Depending on the screen fonts, a U can still look like a zero,” he said. The ISMP has seen cases of misinterpreted abbreviations that have been typed in addition to those that were handwritten, he added.

Additionally, some abbreviations for vastly different drugs are similar. For example, morphine sulfate (MS04) has been mistaken as magnesium sulfate (MgS04).

The campaign strategy involves working with publishers to change style manuals and journals, making materials available to medical schools and pharmaceutical companies, and encouraging anyone who uses these abbreviations to stop using the most dangerous ones, Dr. Cohen said.

An online package includes a slide presentation, reference guide, pocket card, abbreviation list, and patient safety video. Additional strategies include the distribution of brochures to health professionals and the pharmaceutical industry, and the use of public service announcements and posters for medical associations and organizations.

To obtain a complete list of potentially dangerous abbreviations and more educational materials, visit www.fda.gov/cder/drug/mederrorswww.ismp.org/tools/abbreviations

WASHINGTON — The Food and Drug Administration and the Institute for Safe Medication Practices have launched a national education campaign aimed at health care professionals and pharmaceutical companies with the goal of reducing the number of medical mistakes caused by confusing medical abbreviations.

Each year, more than 7,000 deaths occur in the United States as a result of medication errors, and many of these are caused by the misinterpretation of medical abbreviations, Carol Holquist, director of the Division of Medication Errors and Technical Support at the FDA's Center for Drug Evaluation and Research, said at a press conference.

When a “U” looks like a zero, a patient may receive a 10-fold overdose—40 units of insulin rather than 4 units, for example. Dosage designations represent another danger zone: A misplaced or deleted decimal point can turn 1.0 mg into 10 mg, or 0.1 mg into 1 mg.

Yet the ongoing use of error-prone abbreviations, symbols, and dosage designations has not been addressed as the systemic problem that it is, said Michael Cohen, Sc.D., president of the Institute for Safe Medication Practices (ISMP).

The use of electronic prescribing information doesn't solve the problem, Dr. Cohen noted. “Depending on the screen fonts, a U can still look like a zero,” he said. The ISMP has seen cases of misinterpreted abbreviations that have been typed in addition to those that were handwritten, he added.

Additionally, some abbreviations for vastly different drugs are similar. For example, morphine sulfate (MS04) has been mistaken as magnesium sulfate (MgS04).

The campaign strategy involves working with publishers to change style manuals and journals, making materials available to medical schools and pharmaceutical companies, and encouraging anyone who uses these abbreviations to stop using the most dangerous ones, Dr. Cohen said.

An online package includes a slide presentation, reference guide, pocket card, abbreviation list, and patient safety video. Additional strategies include the distribution of brochures to health professionals and the pharmaceutical industry, and the use of public service announcements and posters for medical associations and organizations.

To obtain a complete list of potentially dangerous abbreviations and more educational materials, visit www.fda.gov/cder/drug/mederrorswww.ismp.org/tools/abbreviations

WASHINGTON — The Food and Drug Administration and the Institute for Safe Medication Practices have launched a national education campaign aimed at health care professionals and pharmaceutical companies with the goal of reducing the number of medical mistakes caused by confusing medical abbreviations.

Each year, more than 7,000 deaths occur in the United States as a result of medication errors, and many of these are caused by the misinterpretation of medical abbreviations, Carol Holquist, director of the Division of Medication Errors and Technical Support at the FDA's Center for Drug Evaluation and Research, said at a press conference.

When a “U” looks like a zero, a patient may receive a 10-fold overdose—40 units of insulin rather than 4 units, for example. Dosage designations represent another danger zone: A misplaced or deleted decimal point can turn 1.0 mg into 10 mg, or 0.1 mg into 1 mg.

Yet the ongoing use of error-prone abbreviations, symbols, and dosage designations has not been addressed as the systemic problem that it is, said Michael Cohen, Sc.D., president of the Institute for Safe Medication Practices (ISMP).

The use of electronic prescribing information doesn't solve the problem, Dr. Cohen noted. “Depending on the screen fonts, a U can still look like a zero,” he said. The ISMP has seen cases of misinterpreted abbreviations that have been typed in addition to those that were handwritten, he added.

Additionally, some abbreviations for vastly different drugs are similar. For example, morphine sulfate (MS04) has been mistaken as magnesium sulfate (MgS04).

The campaign strategy involves working with publishers to change style manuals and journals, making materials available to medical schools and pharmaceutical companies, and encouraging anyone who uses these abbreviations to stop using the most dangerous ones, Dr. Cohen said.

An online package includes a slide presentation, reference guide, pocket card, abbreviation list, and patient safety video. Additional strategies include the distribution of brochures to health professionals and the pharmaceutical industry, and the use of public service announcements and posters for medical associations and organizations.

To obtain a complete list of potentially dangerous abbreviations and more educational materials, visit www.fda.gov/cder/drug/mederrorswww.ismp.org/tools/abbreviations