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The goal of Patient Safety is to make our institutions as safe as
possible by reducing preventable medical errors. The teams intend
to foster a culture that encourages and rewards the open identification,
communication and resolution of safety issues. The teams intend to
provide for organizational learning from adverse events and from evidence-based
best practice in efforts to reduce preventable medical errors.
It is the responsibility for all healthcare providers to report unsafe
conditions, near misses and adverse events. You should report an adverse
patient event to your supervisor as soon as you take care of the patients
immediate needs or alert someone who can. Even if the patient does
not appear hurt, you should still report the event so that the caregivers
can watch for signs and symptoms of injury.
Contact Information at BWH:
Janet Barnes, RN, JD, Director of Risk Management 732-6442
Tejal Gandhi, MD, Medical Director for Patient Safety 732-4956
Erin Graydon-Baker, MS, RRT, Patient Safety Manager 732-7543
Contact Information at MGH:
Joan Fitzmaurice, RN, PhD, Director,
Office of Quality & Safety 726-5255
Cy Hopkins, MD, Director, Office of Quality & Safety 724-3075
Marilyn McMahon, JD, Risk Manager 726-2111
In the efforts of Patient Safety, below is a list of Unacceptable
Abbreviations, Acronyms and Symbols that should never be used in the
medical record or prescription ordering.
BWH/MGH LIST OF UNACCEPTABLE ACRONYMS, SYMBOLS AND
ABBREVIATIONS
| MgS04, MS04 |
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|
Use complete spellings |
| Apothecary symbols |
Dram
Minim |
Misunderstood or misread |
Use the metric system "mL" "mg" "mcg" |
| BT |
Bedtime |
Mistaken as "BID" |
Use "hs" |
| ug |
Microgram |
Mistaken for "mg" |
Write out microgram or use "mcg" |
| Per os |
Orally |
The "os" can be mistaken for "left eye" |
Use "PO", "by mouth" or "orally" |
| qn |
Nightly or at bedtime |
Misinterpreted as "qh" every hour |
Use "nightly" |
| / (Slash mark) |
Separates two doses or indicates "per" |
Misread as the number "1" |
Do not use a / mark to separate doses. Use "per" |
| ss |
Sliding scale |
Mistaken for "55" |
Spell out "sliding scale" |
| U or u |
Unit |
Misread as "0" or "4" causing a ten-fold
or greater overdose |
Use "unit" |
| No zero before a decimal dose (.5mg) |
0.5mg |
Misread as 5mg |
Always use a zero before a decimal when the dose is less than
a whole unit |
| Zero after a decimal point (1.0mg) |
1mg |
Misread as 10mg if decimal point not seen |
Do not use terminal zeros for doses expressed in whole numbers |
| Q.D. |
Daily |
Misread as QID |
Write "daily" |
| Q.O.D. |
Every other day |
Misread as QID |
Write "every other day" |
Reference: ISMP (www.ismp.org)
and Lesar et al. JAMA 1997; 277:312-317
JCAHO 01/01/04
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