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Patient Safety

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

 

Unacceptable Abbreviation and/or Symbol
Dose Expression
Intended Meaning Misinterpretation Correction
MgS04, MS04     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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