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If a doctor at Mary Washington Hospital orders ".5 mg" of a medicine and wants the patient to take it "q.d.," the doctor can expect a phone call from one of the the hospital's pharmacists.
"You've used a prohibited abbreviation," the pharmacist will tell the physician. "We have to call and clarify."
The calls are intended to clear up any misunderstanding about potentially dangerous medication abbreviations. But they also remind physicians that the way they've always written medication orders is changing.
Since June 1, the Fredericksburg hospital has banned the use of a dozen easily misinterpreted medication abbreviations. Physicians are now required, for example, to place a zero before the decimal point when prescribing a fractional dose of medicine.
They also are expected to avoid potentially confusing abbreviations such as "q.d.," short for the Latin phrase quaque die. Instead, they must write out "daily" or "every day" if that's how often they want the patient to take a medicine.
The idea behind the hospital's "Dangerous Abbreviations and Dose Designations" list is to make patient stays safer.
"If you're supposed to get Lanoxin, a heart medicine, once a day, and you get it four times a day, that's not a good thing," said Dr. Thomas Ryan, vice president for medical affairs for Mary Washington.
Mary Washington's effort is part of a national campaign to eliminate once-common but potentially lethal abbreviations. The effort has been championed by patient-safety groups such as the Institute for Safe Medication Practices and the U.S. Pharmacopeia. The Joint Commission on Accreditation of Healthcare Organizations also has lent its support.
The accrediting agency sponsored a national summit on dangerous abbreviations last year. In May, it told the nation's hospitals that they should ban the nine abbreviations on its "Do Not Use" list. Mary Washington added three more abbreviations to the list to make an even dozen.
Patients can be at risk when physicians use these abbreviations if the doctor's handwriting is misunderstood, according to the Joint Commission.
"We are trying to move in the direction of more standardization," said Dr. Rich Croteau, executive director for patient safety at the commission.
Problems can arise when the person who fills the order in the hospital pharmacy misinterprets the physician's order. The patient may receive the medicine more often than intended, or in the wrong dose.
The problem is compounded by the sheer volume of prescriptions filled in a typical hospital. At Mary Washington, for example, the medical staff of about 360 doctors sends to the pharmacy about 1,100 order sheets each day. Each order sheet can have from one to 20 different medicines on it, said Karel Cushing Clore, clinical manager for pharmacy services.
Doctors at Mary Washington write their medication orders by hand on the patient floors. A nurse or secretary scans the order and sends it downstairs to the hospital pharmacy.
One of the pharmacists must examine the scanned copy and decipher the doctor's handwriting before filling the order.
Mary Washington officials say that pharmacists have spotted medication orders that could have been misinterpreted. But they said they did not know of any patients injured or killed by the misreading of an illegible order.
"We've been lucky here," Clore said.
But injury and death have occurred at other hospitals.
Between 2000 and 2004, nearly 19,000 error reports from 498 hospitals, linked to abbreviation errors, were filed with the U.S. Pharmacopeia's MEDMARX reporting program.
"A small percentage, less than 1 percent, was categorized as harmful, and none were fatal," the agency reported.
The Institute of Safe Medical Practices reported in 2001 on the death of a 9-month-old baby girl. The child received "5 mg" of morphine two times. The child's physician had ordered ".5 mg" of morphine. The infant died four hours after the second dose.
The cause of the error--the use of a decimal dose without a leading zero--was one of the first medication safety issues ever publicized by the ISMP, more than 25 years ago, the institute said.
"Yet today, misinterpretation of naked decimal points and other dangerous dose expressions and abbreviations continue to shatter the lives of innocent patients," the institute reported in its newsletter.
At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of preventable medical errors, according to the Institute of Medicine. Medication errors are an important part of this toll.
The "naked" decimal point is one of the banned abbreviations on the Joint Commission's list. "Terminal" zeros, or those that follow a decimal point, also are banned.
For example, a "1.0 mg" dose of a medicine can be read as 10 mg if the decimal point is not seen.
Other banned abbreviations include "MgSO4," the abbreviation for magnesium sulfate, which can be mistaken for "MSO4," the abbreviation for morphine sulfate. Physicians are now required to write out the complete drug names.
Of all the prohibited abbreviations, the "cc" abbreviation for cubic centimeter and "q.d." abbreviation for "use daily" are proving the hardest to eradicate, Ryan said.
"It's very hard to wipe out 20 or 30 years of writing that way," added Cushing.
The "cc" can be mistaken for a pair of zeros, Cushing said. Physicians are now expected to substitute the "mL" abbreviation.
The "q.d." abbreviation can be mistaken for "q.i.d.," which would give the patient four times the intended dose.
"Everybody has their own style," Clore said. "They may make that "q" or that "d" differently."
The hospital told physicians on Jan. 1 that it was moving away from these abbreviations. It began a zero-tolerance policy on June 1.
At the beginning of the year, pharmacy workers counted an average of 350 uses of prohibited abbreviations each day.
By the first week in June, the number had dropped to 40 per day. In mid-July, the latest period for which figures are available, the use had dropped to 16 times per day.
Physicians who continue to use the banned abbreviations get a phone call from the pharmacists, and soon will receive a form letter from the hospital administration, Ryan said.
"It has been an immensely successful thing," Ryan said, though he is not completely satisfied.
"Our goals are 100 percent compliance," he said, "and we will do what it takes to achieve those goals."
Much of the medication-ordering system at Mary Washington is automated to prevent human error. A robot in the pharmacy fills the prescription, and nurses match bar codes on the patient and the medicine before administering it.
The missing link in the system is the physician order, which is still handwritten. Ryan said he expects the hospital to adopt a computerized order-entry system in 2007.
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