Hospital Pharmacist
2007;14:213
July/August 2007

News summary

NPSA discourages the use of abbreviations on prescriptions

Use of the abbreviations “u” and “iu” when issuing handwritten prescriptions is formally discouraged by the National Patient Safety Agency.

The Patient Safety Observatory fourth report on medication safety incidents (PDF 1.2MB), published earlier this month, claims that such abbreviations can be misinterpreted as numbers resulting in 10-fold overdoses. “The incidents reviewed reported misunderstandings due to the use of abbreviations or illegible, incomplete or ambiguous prescription instructions,” it says.

The report found that 28 per cent of reported medication incidents in hospitals involved an incorrect dose, strength or frequency — the most common types of incident — at all stages of the medication process.

The report describes seven key priority areas on which the NHS should take action to improve medication safety. These are:

• Increasing reporting and learning from medication incidents

• Implementing NPSA safe medication practice recommendations

• Improving staff skills and competence

• Minimising dosing errors

• Ensuring medicines are not omitted

• Ensuring the correct medicines are given to the correct patients

• Documenting patients’ medicine allergy status

The NPSA says that even small improvements in these areas can make a difference to reduce harm to patients.

According to the report, communication between wards and the hospital’s pharmacy is important in ensuring that supply of medicines is appropriate, safe and timely. “Incidents may occur when a hospital medicines supply system fails or when hospital pharmacy opening or closing times lead to a delay in the right dose and medicine being administered to the patient,” the report points out.

It acknowledges that “active working relationships” have been developed between pharmacists and nurses in some hospitals, working to improve patient safety.

The NPSA also recommends that NHS organisations ensure there is a quality assurance process in place, where chief pharmacists take the lead on improving medicines safety.