Prevalence and Risk Factors for Dangerous Abbreviations in Malaysian Electronic Clinical Notes

Area of Science:

• Medical Informatics
• Clinical Documentation
• Patient Safety

Background:

• Medical abbreviations are prevalent in clinical settings.
• Misinterpretation of abbreviations can lead to patient harm.
• Limited research exists on abbreviation risks in Malaysian electronic discharge summaries.

Purpose of the Study:

• To investigate the prevalence of abbreviations in Malaysian electronic discharge summaries.
• To identify risk factors associated with dangerous abbreviations.
• To propose strategies for improving clinical documentation quality and patient safety.

Main Methods:

• Random sampling and manual annotation of 1102 electronic discharge summaries.
• Assessment of abbreviation ambiguity and danger levels by medical doctors.
• Binary logistic regression analysis to determine predictors of dangerous abbreviations.

Main Results:

• Abbreviations comprised 19% of total words, with 22.6% being ambiguous.
• Over half (52.3%) of ambiguous abbreviations were deemed dangerous.
• Risk factors for dangerous abbreviations include multiple senses, medication-related terms, disorders, and procedures.

Conclusions:

• Ambiguous and context-specific abbreviations increase patient safety risks.
• Implementing automated abbreviation detection and expansion can enhance documentation quality.
• Managing abbreviations is crucial for patient safety and secondary data use.