Context: Abbreviations and acronyms (A&A) are commonly used in both general and clinical settings to simplify and facilitate communication as well as means of saving time, space and effort. However, the use of abbreviations has been linked to patient safety issues. District hospitals operate with a heterogeneous community of healthcare workers presumably with diverse set of A&A in use. The use of A&A in these settings assumes that all have common understanding regarding the A&A used in patient records. We therefore aimed to assess the frequency, nature and healthcare workers' understanding of the meaning of the abbreviations and acronyms used in medical records at a district hospital in Botswana.
Methods: A cross-sectional study was conducted over one month using inpatient medical charts at a district hospital in Botswana to produce a self-administered questionnaire assessing healthcare workers' understanding of abbreviations.
Results: A total of 57 charts were included in the study. The total count of abbreviations, acronyms and symbols was 1693 representing 86 different groups. The score of correctly identified abbreviations was different among the three cadres of healthcare workers (P=0.001) assessed. Overall, the healthcare workers correctly identified 73% of the abbreviations. In fifty of the collated abbreviations (58.1%), participants suggested alternative meaning of the abbreviation.
Conclusion: There is evidence that abbreviations are frequently used in medical notes at a district hospital in a resource limited setting. There is need to standardize abbreviations and acronyms used in clinical care to minimize the potential danger of compromised patient safety in district hospitals and similar settings
Billy M Tsima
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