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Prevalence and risk factors for dangerous abbreviations in Malaysian electronic clinical notes

Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where English is widely used, and elicit the risk factors associated with dangerous abbreviations. We...

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Main Authors: Mohd Sulaiman, Ismat, Bulgiba, Awang, Abdul Kareem, Sameem
Format: Article
Published: SAGE Publications 2023
Subjects:
Q Science (General)
QA75 Electronic computers. Computer science
R Medicine (General)
Online Access:http://eprints.um.edu.my/38533/
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spelling my.um.eprints.385332024-11-04T04:35:09Z http://eprints.um.edu.my/38533/ Prevalence and risk factors for dangerous abbreviations in Malaysian electronic clinical notes Mohd Sulaiman, Ismat Bulgiba, Awang Abdul Kareem, Sameem Q Science (General) QA75 Electronic computers. Computer science R Medicine (General) Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where English is widely used, and elicit the risk factors associated with dangerous abbreviations. We randomly sampled and manually annotated 1102 electronic discharge summaries for abbreviations and their senses. Three medical doctors assigned a danger level to ambiguous abbreviations based on their potential to cause patient harm if misinterpreted. The predictors for dangerous abbreviations were determined using binary logistic regression. Abbreviations accounted for 19% (33,824) of total words; 22.6% (7640) of those abbreviations were ambiguous; and 52.3% (115) of the ambiguous abbreviations were labelled dangerous. Increased risk of danger occurs when abbreviations have more than two senses (OR = 2.991; 95% CI 1.586, 5.641), they are medication-related (OR = 6.240; 95% CI 2.674, 14.558), they are disorders (OR = 7.771; 95% CI 2.054, 29.409) and procedures (OR = 3.492; 95% CI 1.376, 8.860). Reduced risk of danger occurs when abbreviations are confined to a single discipline (OR = 0.519; 95% CI 0.278, 0.967). Managing abbreviations through awareness and implementing automated abbreviation detection and expansion would improve the quality of clinical documentation, patient safety, and the information extracted for secondary purposes. SAGE Publications 2023-03 Article PeerReviewed Mohd Sulaiman, Ismat and Bulgiba, Awang and Abdul Kareem, Sameem (2023) Prevalence and risk factors for dangerous abbreviations in Malaysian electronic clinical notes. Evaluation & the Health Professions, 46 (1). pp. 41-47. ISSN 0163-2787, DOI https://doi.org/10.1177/01632787221142623 <https://doi.org/10.1177/01632787221142623>. 10.1177/01632787221142623
institution Universiti Malaya
building UM Library
collection Institutional Repository
continent Asia
country Malaysia
content_provider Universiti Malaya
content_source UM Research Repository
url_provider http://eprints.um.edu.my/
topic Q Science (General)
QA75 Electronic computers. Computer science
R Medicine (General)
spellingShingle Q Science (General)
QA75 Electronic computers. Computer science
R Medicine (General)
Mohd Sulaiman, Ismat
Bulgiba, Awang
Abdul Kareem, Sameem
Prevalence and risk factors for dangerous abbreviations in Malaysian electronic clinical notes
description Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where English is widely used, and elicit the risk factors associated with dangerous abbreviations. We randomly sampled and manually annotated 1102 electronic discharge summaries for abbreviations and their senses. Three medical doctors assigned a danger level to ambiguous abbreviations based on their potential to cause patient harm if misinterpreted. The predictors for dangerous abbreviations were determined using binary logistic regression. Abbreviations accounted for 19% (33,824) of total words; 22.6% (7640) of those abbreviations were ambiguous; and 52.3% (115) of the ambiguous abbreviations were labelled dangerous. Increased risk of danger occurs when abbreviations have more than two senses (OR = 2.991; 95% CI 1.586, 5.641), they are medication-related (OR = 6.240; 95% CI 2.674, 14.558), they are disorders (OR = 7.771; 95% CI 2.054, 29.409) and procedures (OR = 3.492; 95% CI 1.376, 8.860). Reduced risk of danger occurs when abbreviations are confined to a single discipline (OR = 0.519; 95% CI 0.278, 0.967). Managing abbreviations through awareness and implementing automated abbreviation detection and expansion would improve the quality of clinical documentation, patient safety, and the information extracted for secondary purposes.
format Article
author Mohd Sulaiman, Ismat
Bulgiba, Awang
Abdul Kareem, Sameem
author_facet Mohd Sulaiman, Ismat
Bulgiba, Awang
Abdul Kareem, Sameem
author_sort Mohd Sulaiman, Ismat
title Prevalence and risk factors for dangerous abbreviations in Malaysian electronic clinical notes
title_short Prevalence and risk factors for dangerous abbreviations in Malaysian electronic clinical notes
title_full Prevalence and risk factors for dangerous abbreviations in Malaysian electronic clinical notes
title_fullStr Prevalence and risk factors for dangerous abbreviations in Malaysian electronic clinical notes
title_full_unstemmed Prevalence and risk factors for dangerous abbreviations in Malaysian electronic clinical notes
title_sort prevalence and risk factors for dangerous abbreviations in malaysian electronic clinical notes
publisher SAGE Publications
publishDate 2023
url http://eprints.um.edu.my/38533/
_version_ 1814933218146648064
score 13.211869

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