Department of General Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
Intern Med J. 2020 Sep;50(9):1073-1078. doi: 10.1111/imj.14442.
Healthcare workers often abbreviate for convenience, but ambiguous abbreviations may cause miscommunication, which jeopardises patient care. Robust large-scale research to quantify abbreviation frequency and ambiguity in medical documents is lacking.
To calculate the frequency of abbreviations used in discharge summaries, the proportion of these abbreviations that are ambiguous and the potential utility of auto-expansion software.
We designed a software programme to extract all instances of abbreviations from every General Medical Unit discharge summary from the Royal Melbourne Hospital in 2015. We manually expanded abbreviations using published inventories and clinical experience, logging multiple expansions for any abbreviation if identified. Abbreviations were classified based on well defined criteria as standardised and likely to be well understood, or ambiguous. Outcome measures included the range and frequency of standardised and ambiguous abbreviations, and the feasibility of electronic auto-expansion software based on these measures.
Of the 1 551 537 words analysed from 2336 documents, 137 997 (8.9%) were abbreviations with 1741 distinct abbreviations identified. Most abbreviations (88.7%) had a single expansion. The most common abbreviation was PO (per os/orally), followed by BD (bis in die/twice daily) and 68.1% of abbreviations were standardised, largely pertaining to pathology/chemicals. This meant, however, that a large proportion (31.9%) of abbreviations (2.8% of all words) were ambiguous. The most common ambiguous abbreviation was Pt (patient/physiotherapy), followed by LFT (liver function test/lung function test).
Close to one-third of abbreviations used in general medical discharge summaries were ambiguous. Electronic auto-expansion of ambiguous abbreviations is likely to reduce miscommunication and improve patient safety.
医护人员为了方便经常缩写，但含义模糊的缩写可能会导致沟通不畅，从而危及患者的护理。缺乏对医疗文件中缩写词的频率和模糊性进行大规模、强有力的研究。
计算出院小结中使用的缩写词的频率、这些缩写词中含义模糊的缩写词的比例，以及自动扩展软件的潜在效用。
我们设计了一个软件程序，从 2015 年皇家墨尔本医院的每个普通医疗单位的出院小结中提取所有缩写词。我们使用已发表的清单和临床经验手动扩展缩写词，如果确定的话，会为任何缩写词记录多个扩展。缩写词是根据明确的标准进行分类的，分为标准化的和可能容易理解的，以及模糊的。结果包括标准化和模糊缩写词的范围和频率，以及基于这些措施的电子自动扩展软件的可行性。
在对 2336 份文件中的 1551537 个单词进行分析后，有 137997 个（8.9%）是缩写词，其中确定了 1741 个不同的缩写词。大多数缩写词（88.7%）只有一个扩展。最常见的缩写词是 PO（per os/orally），其次是 BD（bis in die/twice daily），68.1%的缩写词是标准化的，主要涉及病理/化学。这意味着，很大一部分（31.9%）缩写词（占所有单词的 2.8%）是模糊的。最常见的模糊缩写词是 Pt（patient/physiotherapy），其次是 LFT（liver function test/lung function test）。
在普通医疗出院小结中使用的缩写词中，近三分之一是模糊的。对模糊缩写词进行电子自动扩展可能会减少沟通错误，提高患者安全。
