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Medical Terminology: Abbreviations and Documentation Errors

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This 3 page paper discusses abbreviations and documentation errors in the medical field. Bibliography lists 4 sources.

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3 pages (~225 words per page)

File: KV32_HVmdrror.rtf

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of mistakes in medical terminology. Just like the game "telephone," where a phrase repeated down a line of people usually has no resemblance to the original, "certain abbreviations used to convey medication orders may also be misinterpreted due to communication lapses" (Arevalo, 2007). The problem is serious enough that there is a list of "Do Not Use" abbreviations because they can cause serious miscommunications and grave, even fatal, errors (Arevalo, 2007). The most common mistakes are using "QD" to mean "once daily," which accounts for nearly half (43.1%) of all errors; next is the use of "U" for "units"; using "cc" instead of "mL" (they are not the same quantity"; and "MS04" or "MS" for morphine sulfate (Arevalo, 2007). Most errors occurred "at the prescribing node (81 percent)" and most were made by medical staff (78.5%) as compared to nursing (15.1%) and pharmacy (4.2%)" (Arevalo, 2007). The three "most common types of abbreviation-related errors were prescribing (67.5 percent), improper dose/quantity (20.7 percent) and incorrectly prepared medication (3.9 percent)" (Arevalo, 2007). Abbreviations that are incorrect or unclear cause damage in other ways than potentially harming patients. They force doctors, nurses, pharmacy technicians and others to ask for clarification at times when seconds may matter (Arevalo, 2007). At the least, they force people to stop what theyre doing to track down someone who can clarify the abbreviation; once again, this interrupts routine and wastes valuable time (Arevalo, 2007). Should written policies be developed for abbreviation usage? Yes. Many hospitals and clinics are already developing a system for what should be written out. The Stanford Hospital and Clinic has put the following policies in place: "Abbreviations on the dangerous/unapproved list cannot be used" (SHC standardizes abbreviations to ensure patient safety, 2002; hereafter "SHC, 2002"). If printed forms are use, abbreviations have ...

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