JCAHO dangerous abbreviations
Posted By: a&amom on 2007-06-13
In Reply to:
Do physician offices/clinic notes need to comply with this list? I thought JCAHO was joint commission for hospital compliance.
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JCAHO Do Not Use Abbreviations List
This link will take you to the JCAHO site with the "Do Not Use" abbreviations list. Most of the questions you are asking here (i.e. q.d. now being "daily") will be answered on this site.
BOS just came out with a 3rd edition, but not many are using that yet. Try to get a copy of the 2nd edition - it will answer a LOT of questions that will come up for you.
Good luck and welcome back! :-)
dangerous abbreviations
It really depends on the account. Some facilities/doctors really don't care for the new set of guidelines and want their work verbatim precisely. But employers want it practiced just in case for some of the more confusing abbreviations.
Dangerous Abbreviations
Q.D., QD, q.d., qd (daily) = Mistaken for each other = Write "daily".
I woud say this should over ride anything BOS has to say, but we aim to please the client. As transcriptionists though we should be aware of these dangerous abbreviations since it can affect a patient's medical record and how it is interpreted.
Dangerous Abbreviations
"IV" isn't on the Joint Commission list of dangerous abbreviations. Don't take this as an indication that you're getting old--the confusion surrounding those darned abbreviations can be aggravating.
Here are some reasons for the aggravation. You might have seen it on a facility's list in the past or you might have encountered it as a recommendation from a consultant or in a journal article. Before The Joint Commission solidified its list of dangerous abbreviations, there was a lot of confusion about this--some groups banned any and all abbreviations.
There is an abbreviation that is banned because it can be CONFUSED WITH "IV." It's "IU," the abbreviation for "international unit." While it's OK to use IV, some facilities do not want you to use it, reasoning that if IU can be confused with IV, then IV can be confused with IU. And then some would want you to avoid using IV, until they discover that they have to pay extra for you to transcribe "intravenously."
Here is a link to the whole list. The document on The Joint Commission website was broken, so this link is to another website, but it is the same thing. http://www.aapmr.org/hpl/pracguide/jcahosymbols.htm
Thoughts on dangerous abbreviations
You're partly right. Joint Commission has no jurisdiction over a private office setting; however, this was adopted by Joint after it was first given to the national pharmacy assocition. When a doctor has his/her nurse phone in a prescription or writes one himself regardless of private office or inpatient setting, s/he better follow these guidelines.
Having worked in a pharmacy, I understand how critical it is to be able to know EXACTLY what the doctor wants the patient to have presribed. Pharmacy is going down the same path as MT work. Notice how many insurers allow for your prescriptions to go to a mail order company who will fill up to three months of your prescriptions at a time. The first line of defense these companies have (well, really just one anymore as they are becoming the MQ of pharmacies), is to scan the prescription. If it is not written clearly, a body must contact that physician. Addtionally these mail order companies allow MDs to relay prescriptions online. These guidelines better be followed or they will be contacted.
Depending on which division within the mail order pharmacy you work, a tech may fill more than 100 prescriptions an hour. If ONE of those prescriptions is filled incorrectly, it is reported to the State Board of Pharmacy who requires a monetary penalty be forwarded by the company depending on the error classification. If there are too many errors in a given month, the pharmacy is shut down, the supervising PHARMACIST receives (typically) a $5000 fine and a one month to five year suspension of practice, all actions of which are published and distributed to all 50 states in a monthly newsletter.
To say this is all AAMT's fault is ludicrous. To say the doctors are not going to change their ways because they have god complexes is ludicrous. This happened because too many mistakes were being made through haste, bad handwriting, lack of time to thoughtfully write prescriptions, etc. This is today's reality. If you do not adapt, you do not survive. Just ask a Cro-Magnon.
d~
I think you need to look up JCAHO SM
prohibited abbreviations and you will see why you cannot type this. We are talking about acute care here--not some family practice clinic. You must follow JCAHO's directive on abbreviations or the facility receives deficiencies if the organization happens to check that record.
JCAHO has prohibited q.d. and q.i.d. SM
so that is why these 2 are no longer used in any facility that is accredited by that organization.
FYI on the Do not use list per AAMT BOS and JCAHO
Hi everyone! I know this is not going to be easy but we all need to start abiding by the dangerous abbreviation list below and the JCAHO updated list attached. The biggest change will be the "q.d." Please start making these changes immediately. I would suggest putting some of them in your auto correct as it will probably be very helpful. You could put it in there as q.d. and change to daily so if you were to type q.d. by accident, it would change it automatically to daily.
We will give you a few months to get used to these changes and probably by February, we will take points off for QR if any of these errors are found.
Thank you and if you have any questions, please let the QA team know.
POLICY
Dangerous abbreviations listed below are NOT to be used.
Abbreviation
Potential Problem
Preferred Term
U (for unit)
Mistaken as zero, four, or cc.
Write “unit”
IU (for international unit)
Mistaken for IV (intravenous) or 10 (ten)
Write “international unit”
Q.D.
Q.O.D
Q.I.D.
Mistaken for each other. The period after the Q can be mistaken for an “I” and the “O” can be mistaken for “I”.
Write “daily” and “every other day” and “four times a day.
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
Decimal point is missed
Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point (0.X mg)
MS
MSO4
MgSO4
Confused for one another. Can mean morphine sulfate or magnesium sulfate.
Write “morphine sulfate” or “magnesium sulfate”
TIW (Three times weekly)
Confused for twice weekly
Write “three times weekly”
mg
(for microgram)
Mistaken for mg (milligrams) resulting in one thousand-fold dosing overdose.
Write "mcg"
ZnSO4 Can be confused with IV electrolytes
Write “zinc sulfate”
Per os Can be mistaken for “left eye”
Use “PO”, “by mouth,” or “orally”
HERE IS WHAT I HAVE!!! ATTACHED IS FROM THE JCAHO SITE PER THEIR FAQ PAGE ALSO. MAYBE WE CAN ALL REACH A COMMON GROUND HERE AND BE ON THE EXACT PAGE WITHIN THE REGULATORY RULES TOGETHER.
A "minimum list" of dangerous abbreviations, acronyms and symbols
Beginning January 1, 2004, the following items must be included on
each accredited organization's "Do not use" list:
Set
Item
Abbreviation
Potential Problem
Preferred Term
1.
1.
U (for unit)
Mistaken as zero, four or cc.
Write "unit"
2.
2.
IU (for international unit)
Mistaken as IV (intravenous) or 10 (ten)
Write "international unit"
3.
3.
4.
Q.D.,
Q.O.D.
(Latin abbreviation for once daily and every other day)
Mistaken for each other. The period after the Q can be mistaken for an "I" and the "O" can be mistaken for "I"
Write "daily" and "every other day"
4.
5.
6.
Trailing zero
(X.0 mg),
Lack of leading zero (.X mg)
Decimal point is missed
Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point (0.X mg)
5.
7.
8.
9.
MS
MSO4
MgSO4
Confused for one another
Can mean morphine sulfate or magnesium sulfate
Write "morphine sulfate" or "magnesium sulfate"
In addition to the "minimum required list"
The following items should also be considered when expanding the "Do not use" list to include the additional three or more items referenced in the JCAHOFAQ@jcaho.org
Abbreviation
Potential Problem
Preferred Term
µg
(for microgram)
Mistaken for mg (milligrams) resulting in one thousand-fold dosing overdose
Write "mcg"
H.S.
(for half-strength or Latin abbreviation for bedtime)
Mistaken for either half-strength or hour of sleep (at bedtime) q.H.S. mistaken for every hour. All can result in a dosing error.
Write out "half-strength" or "at bedtime"
T.I.W.
(for three times a week)
Mistaken for three times a day or twice weekly resulting in an overdose
Write "3 times weekly" or "three times weekly"
S.C. or S.Q.
(for subcutaneous)
Mistaken as SL for sublingual, or "5 every"
Write "Sub-Q", "subQ", or "subcutaneously"
D/C
(for discharge)
Interpreted as discontinue whatever medications follow (typically discharge meds).
Write "discharge"
c.c.
(for cubic centimeter)
Mistaken for U (units) when poorly written.
Write "ml" for milliliters
A.S., A.D., A.U.
(Latin abbreviation for left, right, or both ears)O.S., O.D., O.U.(Latin abbreviation for left, right, or both eyes)
Mistaken for each other
(e.g., AS for OS, AD for OD, AU for OU, etc.)
Write: "left ear," "right ear" or "both ears;" "left eye," "right eye," or "both eyes
JCAHO has created a set of Frequently Asked Questions (FAQs) that explain the new requirements in greater detail.
It is JCAHO. The most misspelled acronym in medicine! nm
x
JCAHO and AAMT is a crock. Patient safety means not hiring DIMWITS
who can't read or retain what they have been taught. If you don't know what TYPED p.o. means or are confused, do not take care of patients. You are obviously too stupid. Go flip burgers somewhere where someone can instruct you every step of the way and you can do no harm. No brainer. Just a little wrist action and by all means DON'T TOUCH THE HOT GRILL. Think you can remember what that means. HEAT BAD!
Dangerous as far as what? NM
x
Not sure. I just know enough to be dangerous.
x
Is it dangerous to buy used?
Used may be cheaper . . . but is it safe? I hadn't really thought of getting used because I'd hate to get a "problem" computer. However, if it were just as good as new . . . maybe . . .
dangerous abbrevs
Pharmacies make plenty of mistakes on prescriptions and I have never heard of one being shut down. They aren't any better or more careful at their job than anyone else in health care these days - which is to say, the consumer/patient needs to be on their toes at all times because you simply cannot trust anyone to do their job properly.
Yes, sloppy writing is responsible for some of these mistakes, which is one of the reasons why many elements of the AMA, the pharmacist associations, and the pharmaceutical industry are pushing for all drugs to have an individual number assigned, so that medication errors can be eliminated or at least greatly reduced. Thousands of people are injured, make sick or even die from prescription errors every year.
I have been doing MT since the 1970s and I have seen huge changes in health care. Most obvious change is that it has become a BUSINESS rather than a human service. Most if not all involved in health care delivery care foremost about the bottom line and their own "bottoms." Like one of the posters below, I too have noted how long the disclaimers are at the bottom of the H&P and Consults, particularly by the surgeons and interventionalists.
When I started MT, almost no report was more than 1 page long. Now, I sometimes transcribe reports where the "disclaimer" section with risks, benefits, alternatives, possible outcomes explanation is half a page long. This information is already contained in the consent forms that are signed by the patient, so it is redundant to include it on the dictated report, but more and more MDs are doing it. I have also noticed, or perhaps it is just my perception, that all dictators are including more information about patient attitude, knowledge and compliance regarding their (the patient's) regarding their medical condition. Personally, I think that is a good thing - people need to take more responsibility for themselves and stop expecting the doctor to solve all their problems.
Dangerous Abbv. below
I want to know how come a hospital says they are compliant with the list and AAMT guidelines but tell you transcribe ver batim even if incorrect? Can't have it both ways seems to me. I got caught by QA between a rock and a hard place about this but stood my ground. I did ver batim because that was the hospital's wish even though I knew it was wrong dictation. At least I flagged it for QA but it caused a problem. No one seems to have the answer. Next time, I'm not flagging it.
Not just lazy...DANGEROUS
This is how patient care errors are made. I know they hate dictating, but it is very disrespectful to their patients when the doctors won't even attempt to dictate clearly so that their patient's lives are not in jeopardy. They should be chastized by their hospitals and not allowed to dictate like that!
cc is not correct, mL is. cc is a dangerous
x
PO is not a dangerous abbreviation (see msg)
Go to this website:
http://www.ismp.org/tools/errorproneabbreviations.pdf
IV is not a dangerous abbreviation.
For Pitocin it is WAS given.
q is a dangerous abbreviation.
x
If you suspect something dangerous, then
for heaven's sake go and visit a doctor.
Why do you suspect a pulmonary embolism? I dounbt tht you wiklk be able to cough it up. Are you producing some blood when coughing?
It might just be some mucus or phlegm that you cannot lodged in you lungs.
Does your cough produce blood?
Here are the symptoms tht indicate a pulmonary embolism
(blood clot in the lungs):
Google:
'Pulmonary embolism symptoms can vary greatly, depending on how much of your lung is involved, the size of the clot and your overall health — especially the presence or absence of underlying lung disease or heart disease.
Common signs and symptoms include:
Sudden shortness of breath, either when you're active or at rest.
Chest pain that often mimics a heart attack. The pain can occur anywhere in your chest and may radiate to your shoulder, arm, neck or jaw. It may be sharp and stabbing or aching and dull and may become worse when you breathe deeply (pleurisy), cough, eat, bend or stoop. The pain will get worse with exertion but won't go away when you rest.
A cough that produces bloody or blood-streaked sputum.
Rapid heartbeat (tachycardia).
Other signs and symptoms that can occur with pulmonary embolism include:
Wheezing
Leg swelling
Clammy or bluish-colored skin
Excessive sweating
Anxiety
Weak pulse
Lightheadedness or fainting (syncope)
Fever'
If you do not have these symptoms, take an aspirin, drink hot tea with lemon juice and honey, you might just have a cold.
This is extremely dangerous reasoning. SM
It isn't what the "suits" are saying, it is what they are doing. These are two totally different and separate entities. My God, are you so complacent that you cannot even take a look around and see the face of the future? No one is telling anyone to not just "be happy." A little foresight and present thinking is imperative, not only in the MT world but in many other areas of business, especially IT. It's all going over to Asia and it's all same-same there.
Is p.o. considered dangerous abbreviation?
nm
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Snopes lists all the names could come in.
Thanks! I have the dangerous abbreviation list
I was just afraid I was missing something buried in the book somewhere. I just didn't want to be making a mistake. Thanks again.
cc is on the dangerous abbreviation list and should be converted to ml.
x
Not to mention extremely dangerous for your pets - sm
especially the flea collars, shampoos, etc. Totally agree. Awful products. Should be banned completely.
Here's a link to that dangerous abbreviation list
This is the site the BOS recommends visiting, so I did. It is a long list of stuff fer sure! Here's the link...just copy and paste it into browser.
http://www.ismp.org/Tools/errorproneabbreviations.pdf
Hope it helps!
would you like a copy of the DAL(dangerous abbrv. list).
Just so happen my supervisor sent it to me today thinking that a report was mine with a dangerous abbr. listed in it. Let me know if you would like for me to email you a copy.
Lord, preserve me from Sam's Club! That place is dangerous!
That is THE most dangerous thing I think I've ever heard. You don't understand it?!
We have been told to use mL for all, regardless if dictated cc. Dangerous abbrev. blahblahblah nm
x
The Joint Commission's Dangerous Abbreviation List... SM
applies to written entries on a patient's chart, i.e. nurses' notes, doctor's orders, etc. For some insane reason, someone somewhere decided to apply it to transcription as well which is just silly. I work for a facility that has decided not to force transcription to strictly adhere to the dangerous abbreviation list and Joint Commission has not counted it against them in the last three audits.
I will say most MTs where I work do not use qhs, qac or qd. We expand those out because WE (the transcription department) decided that we should for clarification purposes.
My dangerous abbreviation sheet doesn't list...sm
q. as a dangerous abbreviation. It lists q.d. and q.o.d. and q.n. but not just q. by itself. ?
There are so many variables at play that it's dangerous to compare to others along these lines. s
I know that there have been occasions when I've had a run of one of my more familiar docs -- one for whom I have a lot of canned text and who tends to dictate with a great deal of regularity, and quickly -- and I've been able to break the 500 lph barrier, but only briefly. Otherwise, working a large hospital account as I do, with dozens of regular docs and a hundred or so others who just crop up now and then, I can't conceive of anyone averaging anything close to that ... I'm luckly to average above 250-275 lph on a typical day, and some days -- when it's resident and ESL heavy -- that can go down to 150-200.
But, again, it's really pretty silly to compare lph between different MTs unless the variables are the same.
One of those radio financial guys said debit cards are the MOST dangerous to use.
s
abbreviations
On anything that I want expanded and is also used as an abbreviation, I put an x at the end. Such as CHF, I have it as chf and will capitalize and then chfx will spell out congestive heart failure without a problem. I do this for all my abbreviations. Hope this helps.
Abbreviations
I was thinking you could benefit from using a popular website for medical abbreviations. The sites are:
1) www.medilexicon.com
2) www.pharma-lexicon.com
You would enter the abbreviation and it will give you the definition. This is, of course, in addition, to your usual research methods using the search engine such as www.google.com
abbreviations
I do abbreviations like CHF is CHF and chff is congestive heart failure. whatever it is I just double the last letter to get spelled out version.
abbreviations
http://www.medicalabbreviations.biz
ABBREVIATIONS - nm
X
abbreviations sm
I was taught years ago never to abbreviate in a diagnosis. I also would spell it out and put the abbreviation in parentheses as this is his direct dictation and that's how I've always done it. The BOS may disagree but never got called on it. I once wrote a physician a sticky note to please not dictate his diagnoses in abbreviations as they may be misinterpreted. He was nasty about it, but it is a very dangerous thing to do.
Abbreviations
What is proper abbreviation for A Fib?
Abbreviations
Thanks. Thought it was a. fib. but saw it somewhere as A Fib and thought I was wrong. Looked in Stedman's Abbrev and it says AFib
I think it is best not to use abbreviations as much as possible.
In my opinion, I would prefer it typed "okay", but every company has their own opinion. If she is the boss, do it her way.
MM's abbreviations
You would have to add MM's expansions to Smartype yourself, one at a time. Here is a link for her abbreviations:
http://www.mtdaily.com/abbvs.txt
I use Barb Grow's vocabulary that I bought from her about 7 years ago. I don't have contact info for her now though, and I don't know if she still offers her vocabulary. I'd be lost without it. It makes much more sense than what the original Smartype or Stedmans came up with in their vocabularies. Her vocabulary is in the vcb format that goes into Smartype, ready to use.
abbreviations help
try this website:
http://www.medilexicon.com
backing up abbreviations
I'd like to make a backup copy of all my abbreviations on Word Expander. I use Bayscribe for my work. Does anybody know how I can go about backing these up? I'm concerned that all it would take would be a virus or something funky to happen to my PC, and I'd lose all those abbreviations. I have stored over 2,000 my own abbreviations for a total of over 60,000 characters and would really regret all that work if something happened. Thanks. 
backing up abbreviations
Thank you VERY much for the info! Makes sense to me. I'll give it a try. 
List of abbreviations
Yes, they are quite certain how wonderful that "dangerous abbreviations" list is, but don't kid yourself. There are quite a few physicians out there/facilities who don't care for the list and want abbreviations (and dictate them too) the former way; --- q.i.d., q.o.d., t.i.w., q. week, q. Monday, Wednesday, Friday, etc. Shall I go on? I know because I've transcribed from physicians dictating just this way. The docs want it THEIR WAY. Get over yourself.
need help on abbreviations board please...thanks
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