Prevalence of Error-prone Abbreviations a Review of Discharge Summaries in General Medical Wards in Kenyatta National Hospital

Abstract

BACKGROUND Accurate documentation in the medical profession is vital. Shorthand use and abbreviation in medical notation is commonplace. Ambiguity and use of error prone abbreviations are known to be associated with poor patient care. Miscommunication due to wrongful interpretation of abbreviations may lead to mismanagement of patients and poor patient outcome. There is paucity in literature regarding use of shorthand in medical notation in the developing world. This study attempted to bridge this knowledge gap. OBJECTIVE: To determine the frequency of error-prone abbreviations and proportion of ambiguous shorthand in discharge summaries. METHODOLOGY: This was a retrospective, descriptive study at Kenyatta National Hospital (KNH). 288 discharge summaries were selected at random, distributed evenly between the medical wards 7A, 8A, 8B, 8D. Discharge summaries written during the time period 1st January 2015 and 31st December 2015 were randomly selected. A review was used to get the frequency of shorthand, abbreviations and more specifically error-prone abbreviations in each discharge summary. Standard comparative lists of error-prone abbreviations were used. Frequency of these error-prone abbreviations was determined and simple surveys were carried out to demonstrate the most commonly used abbreviations. Abbreviations and shorthand was categorized into one of four different groups based on their level of appropriateness (1). Primary outcome was prevalence of error prone abbreviations in medical discharge summaries from General medical wards in KNH. Secondary outcomes were categorization of abbreviations used based on their degree of ambiguity. Data was compiled onto Microsoft Excel® spread sheet format and analysed by Stata® 12. RESULTS: We analysed 288 discharge summaries, we found the prevalence of error prone abbreviations to be 5.8%. The most common category of abbreviations was universally understood (category 1) which was 78%, followed by inappropriate/ambiguous (category 3) which was 12.5%, followed by understood in context (category 2) at 9% and lastly unknown (category 4) at 0.5%. CONCLUSION: Error prone abbreviations are common in medical discharge summaries, occurring at a frequency of one in seventeen words (5.8% of total words used). The majority of abbreviation use was appropriate and universally accepted, however the prevalence of inappropriate and unknown abbreviations was significant at 13%. This has potential implications on safe and effective patient care. Education regarding use of error prone abbreviations and standardized shorthand in medical notation has clinical value. RECOMMENDATIONS: We recommend that a list of institution approved abbreviations should be available to staff in the medical wards. We also recommend that education to health care professionals regarding the use of error prone abbreviations should be done routinely.