PA PSRS Patient Saf Advis 2007 Mar;4(1):10.
Abbreviation "Gotchas"
Pathology; Radiology
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As discussed in previous PA-PSRS Patient Safety Advisory issues, PA-PSRS reports abound with occurrences involving misunderstanding of abbreviations. Here’s another example of an abbreviation that caused a patient to receive an unintended intervention. 

A physician wrote an order for “HCT,” a common abbreviation for “hematocrit.” The staff transcribed and entered hematocrit for the morning. The physician, however, wanted the patient to receive a CT scan of the head. Because the physician used what the facility’s report identified as an unapproved abbreviation, the patient had blood drawn, but did not receive the CT scan.

If healthcare providers use facility-approved abbreviations, patients are more likely to receive interventions as intended on a timely basis. 

Have you identified other abbreviations that have been open to misinterpretation or have multiple interpretations? If so, let us know by e-mailing your experience to PA-PSRS at support_papsrs@pa.gov.  PA-PSRS will publish these abbreviations in the “Abbreviation ‘Gotchas’” box in future Advisory issues.

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