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Nursing homes are often a beehive of activity as doctors, nurses, and other staff work together round the clock to attend to needs of the residents. With so much to do, it's easy to see why creating work efficiencies is viewed as a good thing. However, when it comes to communicating and documenting information about the residents and using abbreviations to do so, medical professionals could be putting their careers and the lives of the residents they are charged with caring for at risk—and creating an environment that is prime for an incident wherein nursing home professional liability claims may arise. Abbreviations can turn reading charts into a guessing game Ironically, using a plethora of abbreviations to document information about a resident can end up causing more time to decipher than it would have taken to read the completely written out entry. Most important, abbreviations may be easily misunderstood by another reader, with dangerous or deadly implications. Here are some examples of the serious and even life-threatening medical errors that can happen when an abbreviation baffles the reader: - Unintentional overdoses of heparin and insulin can occur when staffers misunderstand an entry of "u," because people use it to mean units.
- Use of "g" for microgram can be mistaken for "mg" for milligrams. Mistaking one for the other means the resident receives ten times the intended dosage.
- An entry reading "pt voided qs" could be interpreted by some as "voiding quantity sufficient," yet others would say it means "voiding every shift."
An abbreviation of "MS04" refers to morphine, say some—yet others believe the reference is to magnesium. The vast difference between administering a mineral and a powerful narcotic pain reliever (and the resulting consequences) cannot be overstated. Make sure everyone is on the same page If the medical staff in the nursing home still can make a good business case for using abbreviations after learning how they can so easily be misunderstood, at least take steps to reduce the chances of nursing home professional liability occurrences by creating an approved list of abbreviations based on those most frequently used in the nursing facility. Make sure the terms selected are those found in traditional textbooks and are reprinted accurately, paying attention to capitalization and periods that may apply. Then make sure every staff member memorizes and subscribes to the list, using the abbreviations consistently. Maintain version control of the list, with additions allowed only by senior management and only after ensuring everyone is educated about use of the new additions. And finally, train staff to never guess at the meaning of an abbreviation; when in doubt, contact the person who wrote the entry for an explanation.
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