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Zoheb_PrevalenceofError-proneAbbreviationsaReviewofDischargeSummariesinGeneralMedicalWardsinKenyattaNationalHospital.pdf

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PREVALENCE OF ERROR-PRONE ABBREVIATIONS

A REVIEW OF DISCHARGE SUMMARIES IN GENERAL MEDICAL WARDS IN

KENYATTA NATIONAL HOSPITAL

A research proposal in partial fulfilment of the requirement for the award of the degree

of Masters of Medicine (Internal Medicine), University of Nairobi, College of Health

Sciences,

Department of Clinical Medicine and Therapeutics

DR ZOHEB SULEMAN

H58/74716/14

DECLARATION

Student Declaration

I declare that this research proposal is my original work and has not been presented in any

other university or institution for the award of the degree or any academic credit.

Dr Zoheb Suleman

Registrar, Department of Clinical Medicine and Therapeutics

University of Nairobi

School of Medicine

SIGNED ……………………………………… Date ………………………………………..

iii

Supervisor’s declaration

This research proposal has been submitted for consideration with approval of my university

supervisors.

Professor E.Ogola

Professor of Medicine, University of Nairobi,

Consultant Physician and Cardiologist, Kenyatta National Hospital

Department of Clinical Medicine and Therapeutics

University of Nairobi.

SIGNED ………………………………………. Date ……………………………………….

Dr M. C. Maritim

Consultant Physician, Lecturer, Kenyatta National Hospital

Department of Clinical Medicine and Therapeutics,

University of Nairobi,

SIGNED ………………………………………. Date ……………………………………….

ACKNOWLEDGEMENT

This proposal for thesis has only been made possible by guidance and encouragement from

my supervisors, Professor Ogola and Dr Maritim, kind words and guidance from various

faculty members and the incessant drive to be better from my classmates and friends.

DEDICATION

I dedicate the time and effort put into this project to my wife and family

TABLE OF CONTENTS

DECLARATION ....................................................................................................................... ii

Supervisor‟s declaration........................................................................................................... iii

ACKNOWLEDGEMENT ........................................................................................................ iv

DEDICATION ........................................................................................................................... v

TABLE OF CONTENTS .......................................................................................................... vi

LIST OF TABLES ................................................................................................................. viii

LIST OF FIGURES .................................................................................................................. ix

ABBREVIATIONS: .................................................................................................................. x

CHAPTER 1: INTRODUCTION AND LITERATURE REVIEW .................................... 1

1.1 Background and introduction ............................................................................................... 1

1.2. Literature review ................................................................................................................. 3

CHAPTER 2: STUDY JUSTIFICATION AND OBJECTIVES ......................................... 9

2.1 STUDY JUSTIFICATION .................................................................................................. 9

2.2 RESEARCH QUESTION .................................................................................................. 10

2.3.1 Broad objective: ......................................................................................................... 10

2.3.2 Specific objective: ...................................................................................................... 10

CHAPTER 3: RESEARCH METHODOLOGY ................................................................ 11

3.1 Study design: Retrospective, descriptive study. ................................................................ 11

3.2 Study Population: ............................................................................................................... 11

3.3 Study site:........................................................................................................................... 11

3.4 Study period: ...................................................................................................................... 12

3.5 Data selection: .................................................................................................................... 12

3.6 Inclusion criteria: ............................................................................................................... 12

3.7 Exclusion criteria: .............................................................................................................. 12

3.8 SAMPLE SIZE .................................................................................................................. 13

3.9 METHODS ........................................................................................................................ 14

3.10 DATA COLLECTION, MANAGEMENT AND ANALYSIS: ..................................... 17

3.11 ETHICAL CONSIDERATIONS ..................................................................................... 18

CHAPTER 4: RESULTS ...................................................................................................... 19

4.1 Subject selection ................................................................................................................ 19

4.2 Prevalence of error prone abbreviations. ........................................................................... 20

vii

4.3 Categorisation of abbreviations ......................................................................................... 24

CHAPTER 5: DISCUSSION, CONCLUSION AND RECOMMENDATIONS.............. 25

5.1 DISCUSSION .................................................................................................................... 25

5.2: STUDY LIMITATIONS ................................................................................................. 30

5.3 CONCLUSION .................................................................................................................. 30

5.4 RECOMMENDATIONS ................................................................................................... 30

REFERENCES: ..................................................................................................................... 31

APPENDIX ............................................................................................................................. 34

Appendix A: DATA COLLECTION TOOL ........................................................................... 34

Appendix B: INDEX FOR ERROR PRONE ABBREVIATIONS ......................................... 41

Appendix C: Completion of discharge summary domains from medical wards in KNH ....... 45

Appendix D: Types of Error prone abbreviations ................................................................... 46

Appendix E: budget and rationale: .......................................................................................... 47

viii

LIST OF TABLES

Table 1: Categorization of abbreviations ................................................................................. 15

Table 2: Total number of error prone abbreviations per ward ................................................. 20

Table 3: Frequency of types of error prone abbreviations in discharge summaries ................ 22

LIST OF FIGURES

Figure 1: Validation of shorthand categorization into levels of ambiguity ............................. 16

Figure 2: Flowchart showing data recruitment procedure ....................................................... 17

Figure 4: Frequency of error prone abbreviations per month in the medical wards in KNH . 21

ABBREVIATIONS:

CCC: Comprehensive Care Centre

DAMA: Discharged against medical advice

GMC: General Medical Council

ISMP: Institute of Safe Medication Practices

JC: The Joint Commission

KNH: Kenyatta National Hospital

KNH-UON ERC: Kenyatta National Hospital - University of Nairobi Ethics and Review

Committee

LAMA: Left against medical advice

MMD: Mosby‟s Medical Dictionary

MOPC: Medical outpatient clinic

NCC MERP: National Coordinating Council for Medication Error Reporting and Prevention

NMC: Nursing and Midwifery Council

OMG: „Oh my god‟

RMH: Royal Melbourne Hospital

TB clinic: Tuberculosis clinic

TID: Trust Intranet Medical Dictionary

ZS: Zoheb Suleman

ABSTRACT/ EXECUTIVE SUMMARY.

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 1 st January 2015 and

31 st 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

xii

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.

CHAPTER 1: INTRODUCTION AND LITERATURE REVIEW

1.1 Background and introduction

The use of shorthand and abbreviations in medical note taking and documentation is

commonplace (1). A discharge summary is a vital document that contains important

information regarding a patient‟s recent admission meant to be conveyed from doctor to

doctor in the same specialty or between different healthcare professionals for example

internal medicine, surgery, physiotherapy, nutrition etc.

The General Medical council‟s (GMC in the United Kingdom) „Good Clinical Care‟ advice

to doctors is to keep accurate and clear clinical records that can be understood by colleagues

(2) (3). The Nursing and Midwifery Council (NMC, United Kingdom) in their Code

recommend that any entries made in paper or electronic records should be clearly written, and

not include unnecessary abbreviations, jargon or speculation (3,4).

In our setup, a discharge summary is given to all patients upon discharge from the ward. The

discharge summary contains vital information regarding patient bio data, the duration of

admission, the admitting ward, consultant, diagnosis, patient complaints, physical

examination findings, investigation, management, discharge medication and follow up dates

and the respective clinic(s). In Kenyatta National Hospital (KNH), the same form is filled

both for discharge summaries and death summaries. Forms are manually filled in duplicate

using carbon paper. The original form is given to the patient and a duplicate kept in the

patient file records.

A different doctor to the admitting one may discharge the patient. Patients are usually

followed up in either a medical outpatient clinic (MOPC) or specialty clinic for example,

renal, chest, tuberculosis clinic (TB clinic) or comprehensive care centre (CCC). At the

respective clinic, the patient may be reviewed by another member of the medical team or

another healthcare professional. Follow up dates are usually days or sometimes weeks later.

Quite often, the handwritten medical discharge summary is the only piece of communication

conveying vital patient information from the ward, to the respective follow up clinic. Patients

are often required to know and understand important information about their drug dosages

and diagnosis (5). When this is not forthcoming, the discharge summary plays an important

role in communication.

In our time conscious profession, various reasons such as high patient turnover and increased

workload, use of shorthand and abbreviations in medical note taking and discharge

summaries is common. Miscommunication due to wrongful interpretation of abbreviations

may lead to mismanagement of patients and poor patient outcome. It is a case of “writing

little and communicating less” (5). Shorthand/abbreviation used by one cadre of healthcare

professionals may not be easily interpreted by another (or even within the same) cadre.

Ambiguous and inappropriate abbreviation makes communication even more difficult.

Furthermore, there are abbreviations known to be error-prone and more liable to

misconstrued, for example µg (microgram), I. U (international unit) and this could lead to

mismanagement of patients (7). Different abbreviations are used for the same word and some

abbreviations can have different meanings.

1.2. Literature review

Shorthand as defined by the Oxford English Dictionary (6) is a method of rapid

writing by means of abbreviations and symbols, used especially for taking dictation. They

also define abbreviations as a shortened form of a word or phrase for example SKU is the

abbreviation for Stock Keeping Unit. Acronym is defined as an abbreviation formed from

the initial letters of other words and pronounced as a word e.g. NASA.

Clinical handover of a patient on discharge from a hospital generally occurs using a

discharge summary. A discharge summary contains information about events during care of a

patient by a provider or organization. It is produced during a patient‟s stay in hospital as

either an admitted or non-admitted patient and issued when or after the patient leaves the care

of the hospital. Clinical handover of a patient especially from acute care to the community

setting is a known area for potential risk and patient harm. Discharge summaries are critical

for providing well-coordinated and effective clinical handover because they are the primary

communication mechanism between hospitals and primary healthcare providers.

Correct documentation in the medical profession cannot be emphasized enough.

Shorthand use and abbreviation in medical notation is common. Ambiguity and use of error

prone abbreviations are known to be associated with impaired patient care. Standardized lists

and guidelines on error-prone abbreviations have been published (7) . In 1996, National

Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

published the first list of error-prone abbreviations (updated in 2014) and called for their

abandonment from clinical practices (8). Extensive lists have also been released by the

Institute of Safe Medication Practices (ISMP) (9), the Joint Commission on Accreditation of

Healthcare Organizations (JC) (10) and the New South Wales Therapeutic Advisory Group,

updated in 2009 by the Australian Commission on Safety and Quality in Healthcare (11). One

of the most extensive lists of error-prone abbreviations is from the ISMP and has been the

http://www.oxforddictionaries.com/definition/english/%20%0ahttp:/www.oxforddictionaries.com/definition/english/abbreviation%23abbreviation__2

http://www.oxforddictionaries.com/definition/english/%20%0ahttp:/www.oxforddictionaries.com/definition/english/initial%23initial__2

http://www.oxforddictionaries.com/definition/english/%20%0ahttp:/www.oxforddictionaries.com/definition/english/pronounce%23pronounce__2

http://www.oxforddictionaries.com/definition/english/%20%0ahttp:/www.oxforddictionaries.com/definition/english/NASA%23NASA__2

foundation of subsequent lists and guidelines. The ISMP list contains The Joint

Commission‟s “minimum list” of dangerous abbreviations, acronyms, and symbols that must

be included on an organization‟s “Do Not Use” list. The Australian Commission on Safety

and Quality in Healthcare has incorporated the ISMP list and an updated 2011 version of this

guideline is available online. This updated list is the standard comparative benchmark that we

used in our study. In December 2016, The Australian Commission on Safety and Quality in

Healthcare released their recommendations for terminology, abbreviations and symbols used

in medicines documentation (11). Apart from a list of safe terms, abbreviations and

dose designations for medicines they also outline some of the principles for safe, clear and

consistent terminology for medicines.

Implementation of these guidelines has not been studied adequately. A study by

Samaranayake et al (12) has shown education regarding proper documentation practices has

impacts the use of error-prone abbreviations. There is paucity in literature regarding use of

shorthand in medical notation. Only a few studies have been done in an internal medicine

setup and fewer still using discharge summaries.

A study by Politis et al in 2014 (1) which sought to describe the frequency of

inappropriate and ambiguous shorthand in discharge summaries was carried out in the

General Medical Units at the Royal Melbourne Hospital, Australia (RMH). Their system uses

electronic discharge summaries. Eighty discharge summaries were reviewed. All

abbreviations were assigned into four categories of appropriateness. The study found that the

discharge summaries contained 840 abbreviations used on 6269 occasions. 20.1% of all

words were abbreviations. 6.8% of the 6269 occasions of shorthand used were categorized as

being „Understood but inappropriate and/or ambiguous‟ or „Unknown‟ (category 3 or 4)

which equated to 1.4% of all words, averaging 5.4 words per discharge summary. They

concluded that abbreviations are commonly used in discharge summaries in general medical

units precisely at a frequency of one in five words. The majority of shorthand used though

appropriate and universally accepted (44% of total abbreviations), there is still frequent use of

ambiguous, inappropriate (6% of total abbreviations) or unknown (1% of total abbreviations)

shorthand. The most common inappropriate or ambiguous abbreviation (category 3) at a

frequency of 5.4% was „GEM‟ referring to the geriatric evaluation and management unit at

RMH. „AP‟ at a frequency of 2.8% referred to alkaline phosphatase. The study recommended

the need for better awareness and education regarding use of shorthand in clinical notation.

This was one of the few studies done in an internal medicine setup, furthermore on

discharge summaries. Merits of this study were that they formulated a method of validating

the categorization of abbreviations into levels of appropriateness.. The study was carried out

in a large teaching hospital with a large population of qualified and trainee doctors.

This study used electronic discharge summaries as it is a computerised health management

system compared to KNH where a manual input handwritten system is used. Entry fields and

parameters in a computerised system will vary from the discharge summary forms used here.

Variables such as legibility of discharge summaries may alter some outcomes. This study did

not assess the prevalence of error-prone abbreviation which is our primary objective.

A study by M.J. Dooley et al in 2010 (7) looked at the prevalence of error-prone

abbreviations used in medication prescribing for hospitalized patients. It was a multi-hospital

evaluation carried out across three Australian hospitals. The study basis was that use of error

prone abbreviations in prescribing was a potential cause of error that may lead to medication

error. The frequency and type of error-prone abbreviations was determined in an inpatient

setting. They looked at inpatient prescription charts. 369 (76.9%) patients had one or more

error-prone abbreviations. 8.4% of orders had at least one error-prone abbreviation. 29.6% of

these abbreviations were considered to be high risk for causing significant injury.

The study by Dooley et al was significant in that the frequency of error-prone

abbreviations of 8.4% was lower than the rates of between 30% and 33% published in other

settings (7). A reason given for this finding could be that the hospitals included in the study

had undergone targeted education for medical staff concerning error-prone abbreviations,

with local case examples given of abbreviations that had previously led to grievous patient

harm. This supports the idea that safe documentation practices can be taught. This study

however did not assess the clinical impact of error-prone abbreviations on adverse drug

reactions.

A study by S.Sinha et al in 2010 (3) carried out in a hospital in the UK assessed the

understanding of commonly used abbreviations in the medical records among healthcare

professionals. It was a cross-sectional observational study on abbreviation use in general

surgical inpatient medical records, randomly selected. They used admissions over a 10 day

period in October 2008. Selected abbreviations in the form of a standard questionnaire were

shown to different members of a multidisciplinary team to examine interpretation and

knowledge. 209 questionnaires were analyzed. The average correct response was 43%.

Foundation year 1 (F1) doctors (which is comparable to medical officer interns in our health

care system) scored the highest, compared to dieticians who scored the lowest (20%).

Different abbreviations were also scored as to percentages of correctness. Certain

abbreviations most often used by nurses (e.g. OTT) achieved a 75% correct response by them

as compared to 11% by F1 students (p<0.001). Similarly, abbreviations such as COBH

(p=0.025) and LUTS (p<0.001) (3), although mostly correctly answered by junior doctors,

were poorly answered by nurses. Junior doctors (foundation year 1 and 2, senior house

officers and registrars) scored more correct answers probably by working in a wider sphere

where they had a more extensive abbreviation repertoire as compared to consultants, nurses

and other allied healthcare professionals who were exposed to only limited areas of their

specialty.

Sinha et al concluded that most healthcare professionals have poor knowledge of

commonly used abbreviations. They suggested use of unambiguous and approved list of

abbreviations to facilitate good communication in patient care.

J.E Sheppard et al in 2007 (13) carried out an audit in the UK to assess the frequency,

nature and understanding of abbreviations in medical records. They looked at abbreviation

use and meaning in paediatric handover sheets and medical notes. Two standards were used,

the Trust Intranet Medical Dictionary (TID) and Mosby‟s Medical Dictionary (MMD). A

collection of abbreviations was shown to healthcare professionals to examine interpretation

of abbreviations.

Twenty five handover sheets were surveyed finding a total of 2286 abbreviations

used, with 221 different abbreviations (13). The standards recognized 14% (TID) and 20%

(MMD) of these abbreviations 168 sets of medical notes had a total of 3668 abbreviations

with 479 different abbreviations; the standards recognized 15% (TID) and 17% (MMD).

Some words had different forms of abbreviations meaning the same thing e.g. normal (N, NI,

NAD) and some abbreviations had multiple interpretations differing from the intended

meaning e.g. TOF (tetralogy of Fallot, trachea-oesophageal fistula) (13). Paediatric doctors

recognized 56-94% and other healthcare professionals recognized 31-63%. Sheppard et al

(13) concluded that abbreviation use was common in paediatric notation. Difficulties in

interpretation were demonstrated. The use of standardized abbreviations to avoid confusion

was suggested.

Samaranayake et al in 2014 (12) studied the effectiveness of a „Do Not Use” list and

perceptions of healthcare professionals on error prone abbreviations. It was an uncontrolled

observational study carried out in a tertiary hospital in Hong Kong. They assessed the use of

error-prone abbreviations included in the „Do Not Use” list before, after its introduction and

after the first reinforcement. 3,238 prescriptions were reviewed. The use of error-prone

abbreviations in the „Do Not Use” list decreased from 7.8 to 3.3% after its introduction

(P<0.001) and to 1.3% after the first reinforcement ( P<0.001). They concluded that a „Do

Not Use” list is effective in reducing error-prone abbreviations. Reinforcements of this list

have been shown to improve adherence (12). Hence education forums on error-prone

abbreviations in hospitals can lead to improvements in safe documentation practices and

improve medical practice in patient management.

CHAPTER 2: STUDY JUSTIFICATION AND OBJECTIVES

2.1 STUDY JUSTIFICATION

Correct documentation in the medical profession is important. Shorthand use and

abbreviation in medical notation is widespread. Ambiguity and use of error prone

abbreviations are known to be associated with impaired patient care. There is paucity of

literature regarding use of shorthand in medical notation. Safe documentation practices can

be taught. Use of institution-derived acceptable abbreviation and do-not-use abbreviation lists

can be formulated and hence standardize the shorthand and abbreviations used for clearer

communication between healthcare professionals.

This study will help fill the knowledge gap in KNH, by determining the prevalence of error-

prone abbreviations, use of inappropriate abbreviations and could help in the formulation of

an institution specific list of error prone abbreviations. Tutorials on the use of error prone

abbreviations, safe documentation practices, and acceptable abbreviations could be

implemented by the institution. This may have an impact on patient management.

2.2 RESEARCH QUESTION

What is the magnitude of the use of error-prone abbreviations in discharge summaries in

general medical wards at Kenyatta National Hospital (KNH).

2.3 STUDY OBJECTIVES

2.3.1 Broad objective:

 To determine the prevalence of error-prone abbreviations and the level of ambiguity

of shorthand and abbreviations used in medical discharge summaries.

2.3.2 Specific objective:

 To determine the frequency of error prone abbreviations in medical discharge

summaries from General medical wards.

 To get the proportion of abbreviations and shorthand that is ambiguous.

CHAPTER 3: RESEARCH METHODOLOGY

3.1 Study design: Retrospective, descriptive study.

3.2 Study Population:

Discharge summaries from a medical ward during the time period 1 st January 2015 to 31

December 2015 as found in the records office originating from the general medical wards.

KNH has eight medical wards: 7A, 7B, 7C, 7D, 8A, 8B, 8C, 8D. 7C is a specialist skin and

chest ward, 8C predominantly oncology. Specialist wards were excluded as our study was

directed at general medical wards only, reason being difference in admission and discharge

rates and mechanisms for inter-ward transfer. Four general medical wards out of six were

selected, in this case 8A, 8B, 8D, 7A. Each ward has approximately one admitting day per

week, following a set rota, keeping total admissions and discharges fairly even between them.

This would be sufficient to eliminate ward bias and also fall within our sampling frame.

3.3 Study site:

Kenyatta National Hospital (KNH) Established in 1901 with a bed capacity of 40, Kenyatta

National Hospital (KNH) became a State Corporation in 1987 with a Board of Management

and is at the apex of the referral system in the Health Sector in Kenya. KNH has 50 wards, 22

out-patient clinics, 24 theatres (16 specialized) and Accident & Emergency Department.

Kenyatta National Hospital is the oldest hospital in Kenya; it was renamed from the King

George VI to Kenyatta National Hospital after Jomo Kenyatta following independence from

the British. It is currently the largest referral and teaching hospital in the country.

KNH currently has a capacity of 1800 beds and over 6000 staff members.

The records department was the principal area of data collection Data records systems are

computerised. Files with the physical discharge summaries are traceable from the records

department with help from the records clerks. There are approximately equal discharges per

ward per month. KNH being a referral hospital, the largest in the region, sees a wide

spectrum of disease ranging from infectious disease, cardiology, gastrointestinal disorders,

haematological, and oncology cases to name just a few.

3.4 Study period:

This study was conducted from December 2016 to March 2017.

3.5 Data selection:

Discharge summaries from January 2015 to 31 st December 2015 from 4 medical wards : 8A,

8B, 8D, 7A.

3.6 Inclusion criteria:

1. Discharge summaries from General medical wards 8A, 8B, 8D, 7A.

2. Discharge summaries written by any of clinical officer, clinical officer intern, medical

officer, medical officer intern, senior house officer Internal medicine.

3. Discharge summaries written during the time period: 1st January 2015 to 31st

December 2015.

3.7 Exclusion criteria:

1. Patients who absconded, or were discharged against medical advice (DAMA), or

signed leaving against medical advice (LAMA) forms.

2. Discharge summaries that have not been signed off i.e. “DOCTOR NAME” and “SIGN”

fields in the discharge summary left blank.

3. Illegible discharge summaries for any cause including poor quality carbon copies.

3.8 SAMPLE SIZE

Daniel‟s formula (14) was used to calculate sample size.

n = Z 2

P(1-P)

d 2

Where

n = sample size,

Z = Z statistic for a level of confidence,

P = expected prevalence or proportion (in proportion of one; if 20%, P = 0.2),

d = precision (in proportion of one; if 5%, d = 0.05).

Daniel‟s formula was used to calculate sample size for an infinite population (where the

population is greater than 50,000).

Based on the study carried out in Australia (1), the prevalence of shorthand was 20%. Using

this proportion with a 95% confidence interval and 5% precision, the sample size was

estimated to be at 245 discharge summaries.

3.9 METHODS

The principal investigator required access to discharge summaries from the medical records

office. 288 discharge summaries were selected at random, distributed evenly between the

medical wards 7A, 8A, 8B, 8D. This meant that 6 discharge summaries were selected from

each month of the calendar year for each ward to ensure equal numbers of discharge

summaries analysed per quarter. Discharge summaries written during the time period 1 st

January 2015 and 31 st December 2015 were used. Sampling method was done by systematic

sampling where every 3 rd

discharge summary used for data extraction from all the summaries

until sample size of 72 from each ward was met.

Data was manually entered using the data collection tool (appendix A). All words

were counted manually. Abbreviations were noted down. Error prone abbreviations were

indexed. Thereafter all entries were input to a spread sheet on MS Excel.

An audit helped get the frequency of error-prone abbreviations and shorthand in each

discharge summary. A standard comparative list of error-prone abbreviations was used from

the New South Wales Therapeutic Advisory Group, Australian Commission on Safety and

Quality in Healthcare (11) to make an index of error prone abbreviations (appendix B). Each

error prone abbreviation had a code number which could be used to formulate tallies.

Frequency of these error-prone abbreviations was determined and simple surveys were

carried out to show the most commonly used abbreviations. This was used to form a list of

the most common error-prone-abbreviations in medical discharge summaries in KNH.

Abbreviations and shorthand were categorized into one of four different groups based

on their level of appropriateness ( as per politis; OMG study) (1). The same tool as a method

of validation was used in our study (Table 1 below). Categories included: 1. Universally

understood, no context needed; 2. Understood only in context; 3. Understood but

inappropriate and /or ambiguous; 4.Unknown.

Initial categorisation of all shorthand was undertaken by the principal investigator and

then revised according to consensus with registrars from internal medicine and surgery. A

panel of 5 medical staff from KNH, were selected at random using convenience sampling

from the medical and surgical wards. 2 surgical registrars were included so as to reduce bias

as to the understanding of an abbreviation by people in different cadres of the medical

profession. as described by Sinha et al (3). They were each given 28 (10% of the 288)

discharge summaries, twenty three of which were selected at random and the other five

selected because they contained at least one category 4 (category 4; unknown) abbreviations.

This method of verification and categorization has previously been described by Politis et al

(1). They were requested to independently categorize the abbreviations into one of the four

possible categories provided, thereafter the responses were reviewed by the principal

investigator and specific criteria for each category were revised and re-categorized.

Table 1: Categorization of abbreviations

Category Explanation

1 „Universally accepted and understood even without context‟.

2 „Understood when in context‟.

3 „Understood but inappropriate and/or ambiguous‟.

4 „Unknown‟.

Figure 1: Validation of shorthand categorization into levels of ambiguity

288 total discharge summaries

10% of discharge summaries chosen (28)

Independent panel of registrars to categorize abbreviations from the 28 chosen

summaries into one of four categories provided

Principal investigator re-categorized shorthand and abbreviation from all 288

discharge summaries based on consensus by the panel of 5 registrars.

3.10 DATA COLLECTION, MANAGEMENT AND ANALYSIS:

Data collection

Figure 2: Flowchart showing data recruitment procedure

Data was collected from the discharge summaries in the records office, compiled onto

Microsoft Excel ® spread sheet format.

Data analysis

Data was manually entered into spread sheets. Data was analysed using computer software

called Stata ® 12 (a data analysis and statistical software). Descriptive statistics were

calculated for the prevalence of all error prone abbreviations and other abbreviations

step1

•Records office

•Discharge summaries dated between 1st January 2015 and 31st December 2015

step2

•Randomization for wards 7A, 8A,8B, 8D

•Selected equal distribution per ward and quaterly for the year 2015

step3 •72 discharge summaries per ward selected and analysed

step4

•Frequency of error-prone abbreviation

•Compared to standardised list

step 5 •Shorthand and abbreviation categorized into degree of ambiguity

Exclusion criteria:

1. Patients who absconded, or were discharged against medical advice (DAMA), or signed leaving against medical advice (LAMA) forms.

2. Discharge summaries not properly signed off.

3. Illegible discharge

summaries for any

cause including

poor quality carbon

copies

3.11 ETHICAL CONSIDERATIONS

1. Permission was sought from the Kenyatta National Hospital/University of Nairobi

Ethics and Research Review Committee (KNH/UON-ERC) to analyze the data

collected from this study as part of the thesis dissertation. Copies of this Protocol, as

well as any subsequent modifications to the document was presented to the above

named committee for written approval prior to commencing the study.

2. Permission was sought from the Kenyatta National Hospital administration prior to

commencing data collection.

3. Confidentiality- this was maintained at all times; no personal identification data from

discharge summaries was recorded. No information concerning the individual study

findings will be released to any unauthorized third party without prior written

approval of the study institution or the Ethics Research Committee.

4. Information sharing- important findings will be made available to policy makers at the

Ministry of Health, the study findings will also be presented to the University of

Nairobi, Department of Clinical Medicine and Therapeutics staff and students. We

also hope to publish these results so as to disseminate the knowledge gained and hope

to contribute to the improvement of documentation practices in Kenyatta National

Hospital.

CHAPTER 4: RESULTS

4.1 Subject selection

Figure 3: Flowchart showing subject selection.

A total of 24,743 words were analysed manually from the 288 discharge summaries sampled.

12,129 abbreviations were present, 49.5% of total words. The average number of

abbreviations per discharge summary was 42.1. Total number of error prone abbreviations

occurring was 1,438. The prevalence of error prone abbreviation use was 5.8% of all words.

One error prone abbreviation was used approximately every seventeenth word. The mean

error prone abbreviation was 5 per discharge summary (SD 5.2) with a minimum of 0 and a

maximum of 43 in a single discharge summary. The average words per discharge summary in

the various wards 7A, 8A, 8B, 8D were 81, 82, 88 and 92 respectively.

4,081 discharge summaries

screened

302 discharge summaries analysed

288 eligible

24,743 words analysed

excluded

4.2 Prevalence of error prone abbreviations.

Table 2: Total number of error prone abbreviations per ward

Ward

Number of error

prone

abbreviations

Percentage of discharge

summaries with error

prone abbreviations

Ward 7A 324 83

Ward 8A 369 88

Ward 8B 370 84

Ward 8D 372 86

Ward not indicated 3 100

Total 1438

Figure 4: Frequency of error prone abbreviations per month in the medical wards in

KNH

Total error prone abbreviations were 1,438 with all four wards contributing approximately

25% to the total. The last quarter of the year had the highest number of error prone

abbreviations. December had the most number of error prone abbreviations at 187.

100

120

140

160

180

200

Frequency of error prone…

Table 3: Frequency of types of error prone abbreviations in discharge summaries

Proportion

discharge

summaries with

error type n(%)

Total

number of

errors in

discharge

summaries

Average

number of

errors per

discharge

summary

Error 1 4 (1.4%) 5 0.02

Error

10 20 (6.9%) 41 0.14

Error

11 122 (42.4%) 310 1.08

Error

20 28 (9.7%) 33 0.11

Error

25 6 (2.1%) 9 0.03

Error

27 3 (1.0%) 3 0.01

Error

28 4 (1.4%) 6 0.02

Error

30 44 (15.3%) 80 0.28

Error

31 147 (51.0%) 359 1.25

Error

33 100 (34.7%) 260 0.90

Error

34 30 (10.4%) 33 0.11

Error

36 4 (1.4%) 4 0.01

Error

37 24 (8.3%) 33 0.11

Error

38 7 (2.4%) 7 0.02

Error

39 49 (17.0%) 59 0.20

Error

40 58 (20.1%) 95 0.33

Error

45 10 (3.5%) 11 0.04

Error

47 36 (12.5%) 37 0.13

Error

49 37 (12.8%) 53 0.18

Error

51 4 (1.4%) 7 0.02

There were 20 different types of error prone abbreviations found in the discharge summaries

sampled. An index of error prone abbreviations can be found in the appendix (see appendix

B). Use of error prone abbreviations was found to be frequent but was limited to only certain

types from the extensive list.

4.3 Categorisation of abbreviations

78%

9.00%

12.50%

0.50%

Figure 5: Percentage of abbreviations according to categories of ambiguity

Universally accepted

Understood in context

Inappropriate or ambiguous

Unknown

CHAPTER 5: DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1 DISCUSSION

The use of abbreviations and shorthand is used frequently in medical discharge

summaries, including those that are error prone, ambiguous (category 3) and unknown

(category 4). Prior to undertaking our study, there was paucity of data concerning the

prevalence of error prone abbreviations and in general, abbreviation/shorthand use in medical

notation in medical facilities in Kenya. The majority of abbreviations used are universally

accepted, however not all primary healthcare providers may have the same level of

understanding as that of specialty registrars in our hospital. This has impact on safe and

effective patient care and highlights the importance of good medical note taking and the

proper transfer of information from the discharging hospital to another facility or primary

healthcare provider.

Our study was similar to previous studies as they have also been done in tertiary set

ups, notably in Hong kong by Sinha et al, the United Kingdom by Sheppard et al and

Australia by Dooley et al and Politis et al. Many studies have used electronic data recording

systems e.g. Politis et al (1) where they described the frequency of inappropriate and

ambiguous shorthand in discharge summaries. Our study looked at the use of shorthand and

abbreviation in hand written notes from discharge summaries in the medical wards as

opposed to electronic discharge summaries. We also used a similar method of categorization

of abbreviations into levels of ambiguity. In contrast to our study, they did not look at use of

error prone abbreviations in their study. A study by M.J. Dooley et al (7) looked at the

prevalence of error-prone abbreviations used in medication prescribing for hospitalized

patients. It was a multi-hospital evaluation carried out across three Australian hospitals. They

looked at inpatient prescription charts and classified error prone abbreviations as high risk

and low risk with the help of clinical pharmacologists. Our study did not look at inpatient

prescription charts, possibly leading to a slightly lower prevalence of error prone

abbreviations. Furthermore we did not classify error prone abbreviations into high or low

risk. Both Dooley et al and our study did not look at any possible adverse patient outcome

relating directly to use of error prone abbreviations. It was out of the scope of our study and

could thus be undertaken as a follow up to this study.

The prevalence of error prone abbreviation of 5.8% was comparable to Dooley et al

(7) who found 8.4% prevalence in their study. This was lower than the figures published in

other studies which showed rates of 30 to 33% (16,17,18). This was likely because our study

strictly looked at error prone abbreviations in discharge summaries and we did not look at

inpatient drug charts, fluid charts or outpatient prescriptions. Error prone abbreviations are

mostly prescription errors (8,9.10,11). In some of the discharge summaries we analysed, the

authors outlined inpatient treatment sheets, discharge drugs, dosages, frequencies and routes

of administration. In other discharge summaries for example only the drug name would be

included without the dose and frequency.

Dooley et al had comparable results to ours and lower than previous studies

elsewhere, possibly because the three hospitals included in the study had undergone targeted

education for medical staff with local case examples being used of abbreviations that had led

to grievous patient harm. Even though KNH has no routine training, we possibly had a lower

prevalence of error prone abbreviations as we did not look at treatment sheets and drug

charts. Error prone abbreviations are predominantly prescription errors according to the

standardized lists published previously (8,9,10,11). Educational interventions have been

shown to be effective in reducing unsafe abbreviations (19).

We discovered that more error prone abbreviations occurred in the last quarter of the

year with December having the highest number of error prone abbreviations from 26

discharge summaries (9% of the total 288). A postulation was that the academic year starts

from September in the University of Nairobi with a new intake of medical registrars. New

doctors or clinical officers in the wards may be untrained in proper documentation practices.

There were 20 different types of error prone abbreviations occurring in the 288 discharge

summaries analysed. These error types were indexed using the ISMP 2015 list of error prone

abbreviations (9) and New South Wales Therapeutic Advisory Group Recommendations for

Terminology, Abbreviations and Symbols used in the Prescribing and Administration of

medicines 2011 (11). Most abbreviations used were category 1 (universally accepted) which

was 78%, followed by category 3 (inappropriate/ ambiguous), category 2 (understood in

context) and category 4 (unknown). This differed from Politis et al as we had more

abbreviations in category 3. This could be because we included error prone abbreviations in

our study which we categorised as inappropriate i.e a category 3 type of abbreviation. Even

though the majority of abbreviations were appropriate and understood, we still found a

significant percentage of abbreviations that were inappropriate and unknown. This is

noteworthy as it has important implications on patient care.

Numbers of error prone abbreviations may differ based on the hospital setup with

different cadres and level of specialization of medical staff. This may influence abbreviation

use and understanding. KNH has a large number of interns and registrars rotating in various

departments in supervised training programs; combined with one of the highest patient

turnovers in this geographical region this may lead to pressure of time and increase in

shorthand use (almost half of all words per discharge summary) and use of error prone

abbreviations. Conversely, institution organized training programs may help with proper

documentation and medical note taking, control abbreviation use and thereby medication

errors.

The mean frequency of abbreviations and shorthand found in our study was 49.5% of

the total number of words analysed. There was not much difference between the four wards

assessed. This was significantly higher than the prevalence of 20.1% found in the study done

by Politis et al. In their study they looked at 80 electronic discharge summaries. These

contained 840 abbreviations used on 6269 occasions.. Our sample size was much larger and

the fact that we have a manual data recording system with handwritten inpatient files,

treatment sheets and discharge summaries most likely contributed to this difference. Our

study did not look at legibility of handwritten discharge summaries. The ISMP has included

both handwritten and typewritten abbreviations in their categorization. Type written

documentation is also prone to use of error prone abbreviations. Poorly written or illegible

hand writing may impact on patient care. Our study focused on the systems in place in our

institution making it a benchmark for future studies that can explore legibility of handwriting,

error prone abbreviations and any adverse outcomes resulting from their use.

The use of abbreviations and shorthand primarily is to reduce the workload in the note

taking process. Easily recognizable and universally acceptable abbreviations do exist. As we

have seen however, some abbreviations are understood in context only whilst some are

ambiguous. When presented with considerable workload as health care workers, we are

bound to abbreviate certain terms and notations. The manual entry system we use in our

hospital may have contributed directly to the high prevalence of abbreviation use (almost half

of all words written). In addition to this we found that the printed forms for discharge

summaries had limited space available to fill in significant patient details like diagnosis,

physical findings, investigations and management. There was sometimes pressure to fill in a

lot of these details into a limited space, on a one page document. Assessing the quality of

discharge summaries was not our primary goal. This could be undertaken as a follow up

study. A separate section for discharge prescriptions instead of inputting everything into one

block as discharge instructions may help reduce the prevalence of error prone abbreviations

and shorthand use.

As an extension to our observation about word crowding in a limited space, we also

assessed the frequency of abbreviation use in the diagnosis data entry field of a discharge

summary. Discharge summaries are a means of communication, from the hospital to the

patient and to other primary healthcare providers. Patients want to/need to know about their

diagnosis. This information should be legible and easily understood. We found 48.3% of

diagnoses in the 288 discharge summaries sampled had at least 2 abbreviations in the

diagnosis section. This meant that patient diagnosis had a potential for misinterpretation by

the patient or primary care giver. It should be noted that this was not a primary objective of

our study. Future studies could assess patient understanding of information provided on

discharge summaries or medical notes.

This study showed that all 288 discharge summaries were left incomplete, with at

least one or more sections left empty. 99% of discharge summaries had no author designation

indicated. This depended on the author indicating by suffix/ prefix their designation of senior

house officer (SHO), medical officer intern (MOI) and so on. A significant proportion of

discharge summaries had incomplete bio data records for the patient. For the clinic timings

and booking section, 89% had the clinic indicated. 96.2% of discharge summaries had the

firm section left blank. Almost all discharge summaries had the name of the clinician filled in

and all were signed, which was part of the inclusion criteria. This helped show that discharge

summaries should be completed well, adding strength to our suggestion that training on

proper documentation practices be carried out involving all cadres of healthcare

professionals. This additional information collected could possibly be used in the future as

part of a post-hoc analysis

5.2: STUDY LIMITATIONS

1. Although the tool to validate categorization of abbreviations by degree of ambiguity

had previously been utilized by Politis et al (1), the tool has not been validated in our

setup. A panel of five faculty members were used to help with categorization of

shorthand to minimize bias.

2. This study being a pilot study in our setup did not look at adverse outcomes which

may be directly related to use of error-prone abbreviations. It was out of the scope of

the pilot study. It is one of the recommendations that future studies may look at this

aspect.

3. This study did not take into account legibility of discharge summaries due to

handwriting as a variable to ambiguity.

5.3 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 is 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.

5.4 RECOMMENDATIONS

We recommend that a list of institution approved abbreviations should be available to staff in

the medical wards. Routine education on proper documentation practices and use of

acceptable abbreviations be carried out. Assessment on quality of discharge summaries could

be undertaken for our hospital.

REFERENCES:

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glossary (OMG) study. Internal medicine journal. 2015;45(4):423-7.

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4. Council NaM. The Code: Professional standards and behaviour for nurses and

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https://www.nmc.org.uk/standards/code/read-the-code-online/#fourth.

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6. Oxford Dictionary Of English. internet. 3rd edition. New York, NY: Oxford University Press,

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writing.

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designations 2015.[ cited 2016 Apr 10] Available from:

https://www.ismp.org/tools/errorproneabbreviations.pdf.

https://www.nmc.org.uk/standards/code/read-the-code-online/#fourth

http://www.nccmerp.org/recommendations-enhance-accuracy-prescription-writing

10. Commission TJ. Official "Do Not Use" List 2009 [updated 3/5/09; cited 2016 Apr 5].

Available from: http://www.jointcommission.org/assets/1/18/dnu_list.pdf.

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content/uploads/2012/01/32060v2.pdf.

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abbreviations: an audit of abbreviations in paediatric note keeping. Archives of disease in

childhood. 2008;93(3):204-6.

14. Daniel WW. Biostatistics: A Foundation for Analysis in the Health Sciences. 9th

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on-screen presentation of discharge summaries. Sydney. ACSQHC; 2016

16. Traynor K. Enforcement outdoes education at eliminating unsafe abbreviations. Am J

Health Syst Pharm 2004; 61: 1314–17.

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practical approach to measure the quality of handwritten medication orders. J Patient Saf

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37: 214–16.

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for terminology, abbreviations and symbols used in medicines documentation. ACSQHC,

Sydney.

APPENDIX

Appendix A: DATA COLLECTION TOOL

Questionnaire number:

Part 1: Background information

Please indicate Ward:

Patient number:

What is the diagnosis?

How many abbreviations in the diagnosis?

Date of admission: Date of discharge:

Author: please circle one (clinical officer/ intern, medical officer/ intern/ registrar)

1. Clinical officer

2. Clinical officer intern

3. Medical officer

4. Medical officer intern

5. Registrar/ senior house officer

Age of the patient

Sex of the patient

Address of the patient

Completed (tick for yes)

Clinic

Firm

Day

Date

Time

Name

Sign

How many words are there total in the discharge summary?

How many abbreviations are there per discharge summary?

How many error-prone abbreviations are there per discharge summary?

Were all the discharge summary fields completed (yes/no?)

Part two: Primary objective: error-prone abbreviations

Abbreviation Intended meaning YES NO

µg Microgram

AD, AS, AU Right ear, left ear, each ear

OD, OS, OU Right eye, left eye, each eye

BT Bedtime

Cc Cubic centimetres

D/C Discharge or discontinue

IJ Injection

IN Intranasal

Half-strength At bedtime

hours of sleep

IU** International unit

o.d. or OD Once daily

OJ Orange juice

Per os By mouth, orally

q.d. or QD** Every day

qhs Nightly at bedtime

qn Nightly or at bedtime

q.o.d. or QOD ** Every other day

q1d Daily

q6PM, etc. Every evening at 6 PM

SC, SQ, sub q Subcutaneous

ss Sliding scale (insulin) or ½ (apothecary)

SSRI

SSI

Sliding scale regular insulin

Sliding scale insulin

i/d One daily

TIW or tiw 3 times a week

U or u** Unit

UD As directed (“ut dictum”)

Trailing zero after

decimal point (e.g.,

1.0 mg)**

1 mg

“Naked” decimal

point (e.g., .5 mg)**

0.5 mg

Abbreviations such as

mg. or mL. with a

period following the

abbreviation

mg mL

Drug name and dose

run together

(especially

problematic for drug

names that end in “l”

such as Inderal40 mg;

Tegretol300 mg)

Inderal 40 mg Tegretol 300 mg

Numerical dose and

unit of measure run

together (e.g., 10mg,

10 mg 100 mL

100mL)

Large doses without

properly placed

commas (e.g.,

100000 units;

1000000 units)

100,000 units 1,000,000 units

APAP Acetaminophen

ARA A vidarabine

AZT zidovudine (Retrovir)

CPZ Compazine (prochlorperazine)

DPT Demerol-Phenergan-Thorazine

DTO Diluted tincture of opium, or deodorized

tincture of opium (Paregoric)

HCl hydrochloric acid or hydrochloride

HCT Hydrocortisone

HCTZ hydrochlorothiazide

MgSO4** magnesium sulphate

MS, MSO4** morphine sulphate

MTX methotrexate

NoAC novel/new oral anticoagulant

PCA procainamide

PTU Propylthiouracil

T3 Tylenol with codeine No. 3

TAC triamcinolone

TNK TNKase

TPA or tPA tissue plasminogen activator, Activase

(alteplase)

ZnSO4 zinc sulphate

“Nitro” drip nitroglycerin infusion

“Norflox” norfloxacin

“IV Vanc” intravenous vancomycin

Other drug

abbreviations

Number:

Part three: Categorisation of ambiguity of abbreviations

Please indicate which abbreviation is present in the discharge summary and categorise

its level of ambiguity according to the following:

1. Universally understood, no context needed.

2. Understood only in context.

3. Understood but inappropriate and /or ambiguous.

4. Unknown.

Total category 1

Total category 2

Total category 3

Total category 4

Abbreviation Category of ambiguity (1-4)

Appendix B: INDEX FOR ERROR PRONE ABBREVIATIONS

Abbreviation Intended meaning Index no.

µg mcg or ug Microgram 1

AD, AS, AU Right ear, left ear, each ear 2

OD, OS, OU Right eye, left eye, each eye 3

BT Bedtime 4

Cc Cubic centimetres 5

D/C Discharge or discontinue 6

IJ Injection 7

IN Intranasal 8

Half-strength At bedtime

hours of sleep

IU** International unit 10

o.d. or OD Once daily 11

OJ Orange juice 12

Per os By mouth, orally 13

q.d. or QD** Every day 14

qhs Nightly at bedtime 15

qn Nightly or at bedtime 16

q.o.d. or QOD ** Every other day 17

q1d Daily 18

q6PM, etc. Every evening at 6 PM 19

SC, SQ, sub q Subcutaneous 20

ss Sliding scale (insulin) or ½

(apothecary)

SSRI

SSI

Sliding scale regular insulin

Sliding scale insulin

i/d One daily 23

TIW or tiw 3 times a week 24

U or u** Unit 25

UD As directed (“ut dictum”) 26

Trailing zero after decimal point (e.g., 1.0

mg)**

1 mg 27

“Naked” decimal point (e.g., .5 mg)** 0.5 mg 28

Abbreviations such as mg. or mL. with a

period following the abbreviation

mg mL 29

Drug name and dose run together

(especially problematic for drug names

that end in “l” such as Inderal40 mg;

Tegretol300 mg)

Inderal 40 mg Tegretol 300 mg 30

Numerical dose and unit of measure run

together (e.g., 10mg, 100mL)

10 mg 100 mL 31

Large doses without properly placed

commas (e.g., 100000 units; 1000000

units)

100,000 units 1,000,000 units 32

Drug name abbreviations eg

APAP

Acetaminophen 33

ARA A vidarabine

AZT zidovudine (Retrovir)

CPZ Compazine (prochlorperazine)

DPT Demerol-Phenergan-Thorazine

DTO Diluted tincture of opium, or

deodorized tincture of opium

(Paregoric)

HCl hydrochloric acid or hydrochloride

HCT Hydrocortisone

HCTZ hydrochlorothiazide

MgSO4** magnesium sulphate

MS, MSO4** morphine sulphate

MTX methotrexate

NoAC novel/new oral anticoagulant

PCA procainamide

PTU Propylthiouracil

T3 Tylenol with codeine No. 3

TAC triamcinolone

TNK TNKase

TPA or tPA tissue plasminogen activator,

Activase (alteplase)

ZnSO4 zinc sulphate

Stemmed drug names “Nitro” drip nitroglycerin infusion 34

“Norflox” norfloxacin

“IV Vanc” intravenous vancomycin

symbols

X3d For 3 days 35

>And < More than and less than 36

/ (slash mark) Separates two doses or indicates per 37

@ At 38

& And 39

+ Plus or and 40

° Hour 41

Ф or ᴓ Zero , null sign 42

OW Once weekly 43

SL or S/L sublingual 44

TID Three times a day 45

6/24 Every 6 hours 46

1/7 For one day 47

1/2 Half 48

i, ii,iii,iv (Roman numerals) 1,2,3,4 etc 49

10*6 etc one million 50

BID, bid Twice a day 51

Appendix C: Completion of discharge summary domains from medical wards in KNH

Domain

Frequency

(n)

Percent

(%)

Designation of author of

prescription No author 284 99

MOI 2 0.7

SHO 1 0.3

Patient address Indicated 34 11.8

Missing 254 88.2

Clinic Indicated 256 88.9

Missing 32 11.1

Firm Indicated 11 3.8

Missing 277 96.2

Date of clinic Indicated 237 82.3

Missing 51 17.7

Time of clinic Indicated 211 73.3

Missing 77 26.7

Name of discharging clinician Present 287 99.7

Missing 1 0.3

Signature of discharging clinician Indicated 288 100

Missing 0 0

Complete discharge summary Yes 0 0

No 288 100

Appendix D: Types of Error prone abbreviations

Table 7: Top 5 types of error prone abbreviations

Error

type

Total

number of

discharge

summaries

with error

type

Total number of

errors in discharge

summaries

Abbreviation Intended

meaning

31 147 359 Numerical dose and unit of

measure run together (e.g.,

10mg, 100mL)

10 mg 100 mL

11 122 310 o.d. or OD Once daily

33 100 260 Drug name abbreviations

AZT

Zidovudine

40 58 95 + Plus or and

39 49 59 & And

Appendix E: budget and rationale:

ITEM QUANTITY UNIT PRICE TOTAL (KSH)

SUPPLIES

Biro Pens 4

20.00

80.00

Pencils 2

12.00

24.00

Box file 2

150.00

300.00

Spring files 2

120.00

240.00

Pencils sharpener 1

45.00

White out pen 1

85.00

Folder 1

120.00

Staple 1

245.00

Paper Punch 1

550.00

Staple Remover 1

235.00

Note book 2

85.00

170.00

TOTAL SUPPLIES

2,094.00

OTHERS

Printing 1

8,000.00

Photocopying 400

3.00

1,200.00

Final proposal booklet 8

500.00

4,000.00

Ethic committee book 1

2,000.00

TOTAL OTHER

15,200.00

Communication 1

5,000.00

Transport 1

5,000.00

Data Statistician 1

20,000.00

TOTAL

PERSONNEL

30,000.00

TOTAL EXPENSES

47,294.00

This budget includes the cost of supplies (which would include stationery) and others which

consists of printing, photocopying, and ethics charges. Total personnel costs include;

transport costs to and from Kenyatta National Hospital, communication and data analysis by

the statistician. Total will amount to 47,294.00 Kenyan shillings only.