The Pharmaceutical Journal Vol 267 No 7164 p321-324
8 September 2001

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Medication errors

Dangers of abbreviation and colour-coding

From Dr J. F. Pickup, MRPharmS

Harriet Adcock’s excellent report (PDF* 50K) on medication errors (PJ, 1 September, p287) is to be commended for drawing attention to this most important topic. Two points deserved more emphasis, I believe.

The use of abbreviations in written communication was mentioned briefly. Although the examples given are certainly important, it is not right to try to say that some are more important than others. The use of abbreviated medieval dog-Latin as a form of private code, while perhaps once justifiable, must now be deprecated, but beyond that, all abbreviations should be avoided. (The article itself, perhaps consciously, contained convincing evidence of the dangers of abbreviation in one of its tables: confusing micrograms and milligrams leads to a 1,000-fold error, not a 10-fold error as reported.)

The other point, not mentioned at all, was the use of colour-coding. The recent “Report to the Committee on Safety of Medicines from the working group on labelling and packaging of medicines” (PJ, 25 August, p252, and 1 September, p286) contains a compelling condemnation of colour-coding (Paragraph 8.2). To the arguments advanced by the working party one should add that local colour-codes, such as that reportedly introduced at Alder Hey

(http://news.bbc.co.uk/hi/english/health/newsid_1516000/1516546.stm) are particularly dangerous since staff trained in one hospital may carry with them the erroneous belief that the codes used are universal when they leave to work elsewhere.

John Pickup
Principal Pharmacist,
Cornwall IT Services,
Royal Cornwall Hospital
Truro

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