The use of abbreviations is general practice among health professionals, particularly in the hospital setting. The Institute for the Safe Medication Practices (El Instituto para Uso Seguro del Medicamento) has published specific recommendations to avoid errors in the medication-use cycle. This study analyses the abbreviations, symbols and expressions used by nursing professionals.
To determine the use of abbreviations and symbols in the medication administration sheet and standard care plans, and if it affects the patient follow-up in the nursing observations sheet.
A cross-sectional descriptive study was conducted on a randomised and simple sample on 100 patients admitted to the Neurology Unit, and whose stays were longer than 3 days, between November 2009 and March 2010.
Variables: non-standard abbreviations, symbols and expressions.
Data sources: medication administration sheet, standardised care plans, nursing observation sheets.
Statistical analysis: Excel 2007.
The medication administration sheet had 43 different abbreviations, with a mean of 5.8, and 11 different symbols (mean 0.8).
The nursing observations sheet had expressions that were difficult to understand; therefore they did not give any relevant information on the progress of the patient. The interpretation may vary depending on who reads them: goes to his reference hospital; impatient; is not tall; wound better, abundant urine; took something; slightly disoriented.
The abbreviations and symbols that are used in the institution need to be standardised, as well as establishing those that cannot be used, following the recommendations of the international organisations on patient safety.