Policy No.: D0209

Spell it Out: Standardised terminology,
abbreviations and symbols to be used
when communicating about medicines

Policy Directive

Version No.: 3.0
Approval date: 06/08/2018

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Contents

1. Policy Statement .................................................................................................................. 3

2. Roles and Responsibilities .................................................................................................. 3

3. Policy Requirements............................................................................................................ 4

4. Implementation &amp; Monitoring ............................................................................................... 4

5. National Safety and Quality Health Service Standards ....................................................... 5

6. Definitions ............................................................................................................................ 6

7. Associated Policy Directives / Policy Guidelines and Resources ....................................... 6

8. Document Ownership &amp; History .......................................................................................... 6

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Spell it Out: Standardised terminology, abbreviations
and symbols to be used when communicating about

medicines Policy Directive

1. Policy Statement

1.1 SA Health is committed to the Quality Use of Medicines (QUM).

1.2 SA Health is committed to raising awareness to the importance of clear communication
when prescribing, dispensing and administering medications, and when documenting
medicines information.

1.3 The purpose of this policy is to promote patient safety through the use of clear and
unambiguous communication of medicines information based on the Australian
Commission on Safety and Quality in Health Care s (the Commission s) Recommendations
for terminology, abbreviations and symbols used in medicines documentation (the
Recommendations) by establishing:

? principles for safe, clear and consistent terminology for medicines

? a set of recommended terms, acceptable abbreviations and dose designations for

medicines.

2. Roles and Responsibilities

2.1 Chief Executive, SA Health will:

? ensure SA public hospitals and health services are aware of and comply with this

policy.

2.2 Director, Medicines and Technology Programs, SA Health will:

? establish, maintain and periodically review the effectiveness of the Spell it Out:

Standardised terminology, abbreviations and symbols to be used when

communicating about medicines Policy Directive

? monitor and evaluate implementation of the directive at a Local Health Network

(LHN) level through LHN reporting to the South Australian Medication Safety

Advisory Group (SAMSAG)

? provide advice to health services in response to specific queries regarding

standardised terminology, abbreviations and symbols used in medicines

documentation.

2.3 Local Health Network and Statewide Services Chief Executive Officers will:

? implement the policy directive and promote implementation of the principles and

recommended terminology, abbreviations and dose designations into protocols,

practices and educational programs within their area of control

? delegate the day to day responsibility for complying with this policy to the relevant

senior managers

? ensure governance arrangements for medication management and medication

safety include specific responsibility for the use of clear and unambiguous

terminology, abbreviations and symbols when communicating about medicines.

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2.4 Executive Directors, Directors, Heads of Service/Departments and other Senior

Managers will:

? ensure risks associated with the use of unsafe terminology, abbreviations and

symbols when communicating about medicines are identified and assessed, and

that actions to reduce identified risks are implemented and evaluated

? promote staff awareness of the Commission s Recommendations for terminology,

abbreviations and symbols used in medicines documentation

? ensure local policies and procedures are implemented for appropriate terminology,

abbreviations and symbols used in medicines documentation

? ensure incidents involving error-prone abbreviations, terminology and symbols are

reported to the Safety Learning System (SLS) and via other appropriate pathways

and managed in accordance with the Patient Incident Management and Open

Disclosure Policy Directive.

2.5 SA Health employees will:

? ensure they are familiar with the Commission s Recommendations, including the:

? principles for safe, clear and consistent terminology for medicines

? list of safe terms, abbreviations and dose designations for medicines

? ensure they comply with the principles and recommended terms, acceptable

abbreviations and dose designations when prescribing, dispensing and

administering medications and in medicines documentation

? ensure incidents involving error-prone abbreviations, terminology and symbols are

reported to the Safety Learning System (SLS) and via other appropriate pathways

and managed in accordance with the Patient Incident Management and Open

Disclosure Policy Directive.

3. Policy Requirements

3.1 Principles

SA Health is committed to the Quality Use of Medicines (QUM) and to raising awareness to
the importance of clear communication when prescribing, dispensing and administering
medications, and when documenting medicines information.

This policy promotes patient safety through the use of clear and unambiguous
communication of medicines information based on the Commission s Recommendations
for terminology, abbreviations and symbols used in medicines documentation by
establishing:

? principles for safe, clear and consistent terminology for medicines

? a set of recommended terms, acceptable abbreviations and dose designations for

medicines.

3.2 Detail

3.2.1 The principles for safe, clear and consistent terminology for medicines, acceptable

terms, abbreviations and dose designations, including dose forms, units of measure

and concentration, and routes of administration as outlined in the Commission s

Recommendations must be adhered to for:

? all medication orders or prescriptions that are hand written, pre-printed,

computer generated (printed hard copy) or electronic

? all communications and records concerning medication documentation,

including local policies, protocols and procedures

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? all labels for medicine storage.

3.2.2 Before deciding to include additional terminology not listed in the Commission s

Recommendations in local policies, the principles outlined in the Recommendations

must be applied and a risk assessment undertaken.

3.2.3 It is acknowledged that there may be potential limitations in utilising all the

recommendations in the electronic environment. Where there is variation from the

Recommendations, a risk assessment is recommended and where required, risk

management strategies implemented.

? In most cases, the Recommendations align with recommendations described

in the National guidelines for the on-screen display of clinical medicines

information and Australian Medicines Terminology.

4. Implementation &amp; Monitoring

It is the responsibility of LHNs to implement the principles of this policy and to monitor the
outcomes. This may be achieved by assessing ongoing progress and performance by utilising the
following indicators:

? National Quality Use of Medicines Indicators for Australian Hospitals. Indicator 3.3:

Percentage of medication orders that include error-prone abbreviations

? National Inpatient Medication Chart Audit

5. National Safety and Quality Health Service Standards

Please note these National Standards above apply until 31 December 2018.

The National Standards below will be implemented from 1 January 2019.

National
Standard 1

Governance

for Safety
and Quality

in Health
Care

National
Standard 2

Partnering

with
Consumers

National
Standard 3

Preventing

&amp;
Controlling
Healthcare
associated
infections

National
Standard 4

Medication

Safety

National
Standard 5

Patient

Identification
&amp; Procedure

Matching

National
Standard 6

Clinical

Handover

National
Standard 7

Blood and

Blood
Products

National
Standard 8

Preventing

&amp;
Managing
Pressure
Injuries

National
Standard 9

Recognising &amp;
Responding to

Clinical
Deterioration

National
Standard 10

Preventing

Falls &amp;
Harm from

Falls

? ? ? ? ? ? ? ? ? ?

National Standard
1

Clinical
Governance

National
Standard 2

Partnering

with
Consumers

National
Standard 3

Preventing &amp;
Controlling
Healthcare-
Associated
Infection

National
Standard 4

Medication

Safety

National
Standard 5

Comprehensiv

e Care

National
Standard 6

Communica

ting for
Safety

National
Standard 7

Blood

Management

National
Standard 8

Recognising &amp;
Responding to

Acute
Deterioration

? ? ? ? ? ? ? ?

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The Medication Safety Standard aims to ensure clinicians are competent to safely prescribe,
dispense and administer appropriate medicines and monitor medicines use, and patients and/or
carers are informed regarding treatment options, benefits and associated risks.

The Communicating for Safety Standard aims to ensure timely, purpose-driven and effective
communication and documentation that supports continuous, coordinated and safe care for
patients.

6. Definitions

In the context of this document:

? Local policies means policies adopted in individual hospitals or health services.

7. Associated Policy Directives / Policy Guidelines and Resources

7.1 Patient Incident Management and Open Disclosure Policy Directive

7.2 Australian Commission on Safety and Quality in Health Care (2016). Recommendations for
terminology, abbreviations and symbols used in medicines documentation. ACSQHC,
Sydney.

7.3 Spell it out Standards. SA Health. Standardised terminology, abbreviations and symbols to
be used when communicating about medicines.

8. Document Ownership &amp; History

Approval
Date

Version
Who approved New /
Revised Version

Reason for Change

06/08/2018 v 3.0

Formally reviewed in line with 5 year
scheduled timeline for review.

? Policy detail unchanged

? Commission reference document
updated from original version

? Transferred to new SA Health
template.

28/05/2013 v 2.0 OCE
Minor amendment to reflect impact on
EPAS and Branch name change

28/02/2011 v 1.1 OCE
Minor amendment - titles of regional CEOs
to Local Health Network CEOs

17/12/2009 v 1.0 Portfolio Executive Original PE approved version.

Document developed by: Medicines and Technology Programs

File / Objective No.: 2009-15524 | A850696

Next review due: 01/06/2023

Policy history: Is this a new policy (V1)? N

Does this policy amend or update an existing policy version? Y

If so, which version? v 2.0

Does this policy replace another policy with a different title? N

If so, which policy (title)? N/A

ISBN No.: 978-1-76083-036-6

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