Recognition of the extent of medication errors resulting from misinterpretation of instructions have resulted in a multitude of recommended practices to reduce the likelihood. One area which may contribute to error, but one which has received less attention, is that of accurate interpretation of clinical chemistry results. It is well recognised that numbers containing decimal places can lead to error in medications with decimals overlooked or misplaced. Anecdotal evidence from Emergency Physicians indicates difficulty in interpreting clinical chemistry results which are presented with leading decimals (e.g. 0.0095 g/l).
Misconceptions about decimals have been the subject of extensive study. Half of student teachers were unable to place 0.606, 0.0666, 0.6, 0.66 and 0.060 in correct sequence and 40 per cent of nurses demonstrated a lack of basic computational ability with, and incomplete or incorrect conceptual understanding of, decimals. No research has been found to-date with medical staff. Whilst remedial teaching is beneficial it may not be a practical solution to the identified problem within the Emergency Department. Rather a change in the presentation of results may provide a simple and practical solution; for example the presentation of Troponin 1 as 40 pg/ml rather than 0.04 ng/ml. Such change will not be effected however without evidence of need.
The goal of the research is to provide recommendations which ultimately could lead to improvements in patient safety. The more modest project objectives are to increase user friendliness of results and reduce the potential for errors.
Dr Michael Sinnott