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The use of abbreviations and acronyms in healthcare has become an international patient safety issue. Common problems include ambiguous, unfamiliar, and look-alike abbreviations and acronyms leading to misinterpretation and medical errors. The Joint Commission mandated the implementation of its "do not use" list in 2004 prohibiting the use of a minimum number of abbreviations. The Institute for Safe Medication Practices (ISMP) has been a champion in the drive to warn both the healthcare community and the public. The problem continues as institutions attempt to comply and ensure patient safety by various strategies including education, enforcement, and leadership. The scope of the problem is far greater than the list provides for; the solutions have not been elucidated by the literature and implementation challenges have yet to be conquered. Recommendations for best practice and implementation are included.
Jake was an 8-year-old male who arrived to the Perioperative area of a pediatric tertiary care center for his short procedure. He was a precocious child who interacted well with staff and, in particular, required detailed scientific explanations of the steps involved in and events leading up to his surgery. Our stretcher ride to the Operating Room (OR) was complemented by questions and developmentally adjusted answers about the procedure, the players, the timing, pain concerns, and an 8-year-old's fascination with the world of technology. As we entered the OR the chatter continued. The induction of anesthesia was smooth. My colleagues were respectful, and childfocused, cooperating fully with our usual astronaut trip from Philadelphia to the moon, the destination reflecting of the age of the nursing staff present. An anesthesia colleague commented on our choice of distraction techniques for a child with MRCP. Wrong child, I thought. He persisted. This might have been a usual case in a usual day in the life of the operating room, except that the documentation in the chart, both hand-written and more recent electronic records, matched his comment. It read, "8-year-old male, with MRCP... ."
Old charts always accompany patients to surgery. Page after page from the present back in time contained notations, which included the term MRCP, an abbreviation commonly, used to denote: Mentally Retarded/Cerebral Palsy. His clinical presentation was in obvious contrast with this diagnosis. Persistence and time allowed us to uncover...