Recommendations for terminology, abbreviations and symbols used in medicines documentation
One of the major causes of medication errors is the use of error-prone abbreviations and dose expressions. To promote patient safety, the Recommendations for Terminology, Abbreviations and Symbols used in Medicines Documentation sets out principles for safe, clear and consistent terminology for medicines, and safe terms, abbreviations and dose designations for medicines.
Abbreviations and terminology as safety issues
Medication errors are one of the most commonly reported clinical incidents in acute health care settings. Rates of serious harm are low, but many medication errors are preventable.
An abbreviation, term or symbol used by a prescriber may mean something quite different to the person interpreting the medicine order.
Abbreviations that appear unclear, ambiguous or incomplete may be misunderstood. When combined with other words or numerals, it may appear as something completely unintended. These terminologies are error‑prone and are a critical patient safety issue.
Rapid literature review
In 2023 the Commission engaged a team from Macquarie University, Australian Institute of Healthcare Innovation, to conduct a Rapid literature review to consider the safety issues related to incidents and reports regarding the use of safe and unsafe abbreviations, terminology and symbols, drawn from relevant literature; policies, policy directives and/or standards; and the Commission’s issues registers from January 2017 to January 2023. This work was led by Dr Magda Raban. The Rapid literature review proposes several changes:
- Enhance the differentiation between application within the paper-based versus digital environments
- Ensure the scope with respect to digital devices is clear
- Include additional examples of abbreviations and symbols to avoid
- Expand the guidance related to abbreviations and terminology for modified-release medicines
- Include advice on risk assessment when deviating from the Commission’s Recommendations for terminology, abbreviations and symbols used in medicines and documentation (2016 Publication).
The findings from the Rapid literature review will inform the review of the 2016 Publication in consultation with key stakeholders.