The Institute for Safe Medication Practices (ISMP) is warning pharmacists and medical practitioners about the potentially severe consequences of using abbreviations for drug names. Their recent report, submitted to the National Medication Errors Reporting Program, sheds crucial light onto one way in which patients could be injured by a Maryland pharmacy error—through miscommunications and mix-ups based on drug abbreviations.
For example, according to an article discussing the ISMP’s report, one commonly confusing abbreviation is “tPA,” which refers to “tissue plasminogen activator alteplase (Activase).” In one situation, an urgent order for alteplase for a patient in an intensive care unit (ICU) was sent to the pharmacy. A nurse from the ICU called the pharmacy to ask if the “tPA” was ready, but the pharmacist, who was newly hired and unfamiliar with the abbreviation tPA, thought the request was for “TPN,” or “total parenteral nutrition.” The pharmacist then told the nurse that the drug would be there in a few minutes, since they were currently mixing parenteral nutrition solutions.
Later that day, when the needed alteplase did not arrive, the ICU nurse called the pharmacy again. Another pharmacist answered, saw the urgent order in the database, and began to dispense a dosage of the drug. Unfortunately, in her rush, she forgot to mix the drug according to the protocol for inpatient use and was delayed while re-dispensing and mixing the drug. This delay, since the drug was already delayed due to the abbreviation mix-up earlier, led to the hospital calling a rapid response team for the patient in question.