PA-PSRS reports abound with occurrences involving misunderstanding of abbreviations. While many of these confusing abbreviations are related to medication orders, these recent examples don’t involve medications:
An order indicated, “KUB/CX OBST SERIES.” The physician intended this to mean to cancel (CX) the kidneys/ureters/bladder (KUB) series and to perform an Obstruction (OBST) Series. The X-ray Technician misinterpreted the CX. The patient received a chest X-ray (commonly abbreviated as CXR).
A physician ordered “SDP,” intending the patient to receive Single Donor Platelets. In Blood Bank, however, SDP is an abbreviation for Solvent/Detergenttreated Plasma, which is what was given to the patient.
A chart notation indicated UH (umbilical hernia) repair, which the surgical resident misinterpreted as LIH (left inguinal hernia) repair. The resident marked the patient’s left inguinal area. Fortunately, the site marking error was discovered by the attending surgeon prior to the procedure.
You may want to consider adding these abbreviations to your Do Not Use abbreviation list. Also, a multidisciplinary evaluation of facility abbreviations may reveal that a given abbreviation might have different meanings in different departments. Identical/similar abbreviations for diagnostic tests may be identified if the facility evaluates its computerized order entry screens.
Have you identified other abbreviations that have been open to misinterpretation or have multiple interpretations? If so, let us know by e-mailing your experience to PA-PSRS at Support_papsrs@state.pa.us.
We’ll place these abbreviations in the Abbreviations “Gotchas” box in future issues.