Doctors have been urged not to use ambiguous abbreviations in medical notes, after a Victorian hospital audit found a worryingly high number of confusing terms in discharge summaries.
While the average healthcare professional may understand common abbreviations such as ‘GP’ and ‘PRN’, they may be confused by ambiguous ones such as ‘AP’ (Anteroposterior? Abdominoperineal? Assessment and plan?), according to researchers.
In an audit of 2,336 discharge summaries, Dr Sarah Holper and colleagues at the Royal Melbourne Hospital and the Alfred hospital found that 9% of the 1.65 million words analysed were abbreviations, with an average of 59 abbreviations used per summary.
There were 1,741 distinct abbreviations detected, of which about two thirds were standardised ones such as PO (per os/orally), and BD (bis in die/twice daily).
But a third of the abbreviations – accounting for 3% of all words used in discharge summaries – were ambiguous ones (see table).
Writing in Internal Medicine Journal, the researchers said that while abbreviation offered a time-saving convenience, it was important to stick to standardised ones to avoid potential medical errors.
“Beyond mere confusion, misinterpretation of abbreviations may lead to inappropriate, delayed or even deleterious patient care,” they wrote.
As a solution, they proposed the incorporation of auto-expand software into electronic record systems, which would prompt the writer for clarification of ambiguous terms.
“With the average summary being 664 words long, auto-expansion would occur approximately 19 times per summary and 5.5 of these would require writer clarification,” they noted.
Top 10 ambiguous abbreviations:
- Pt (patient/physiotherapy) 19%
- LFT (liver function test/lung function test) 16%
- AF (atrial fibrillation/flutter) 11%
- Sats (saturations) 10%
- D/C (discharge) 8%
- AP (anteroposterior/abdominoperineal/assessment and plan) 8%
- HTN (hypertension) 8%
- GEM (Geriatric Evaluation and Management) 8%
- IHD (ischaemic heart disease) 7%