Ambiguous medical abbreviation study: challenges and opportunities

Abstract

Background: Healthcare workers often abbreviate for convenience, but ambiguous abbreviations may cause miscommunication, which jeopardises patient care. Robust large-scale research to quantify abbreviation frequency and ambiguity in medical documents is lacking. Aims: To calculate the frequency of abbreviations used in discharge summaries, the proportion of these abbreviations that are ambiguous and the potential utility of auto-expansion software. Methods: We designed a software programme to extract all instances of abbreviations from every General Medical Unit discharge summary from the Royal Melbourne Hospital in 2015. We manually expanded abbreviations using published inventories and cli..