Words: mightier than swords and deadly when misused in labels

Sir Francis Bacon was the Daniel Kahneman of his day, exposing the frailties of the human mind. In Novum Organum, he pointed to fallacies that result from how the mind reconstructs the world.

He described four images or ‘idols’ that human beings invent and falsely worship. These idols contain a distortion of reality. He regarded the most important of his four idols to be the ‘idols of the market’, and included under this idol the misuse of words.

The use of words in the NHS has occasionally come under scrutiny, and includes the call by the British Medical Journal in 2001 to ban ‘accidents’, arguing that the use of this term was sometimes inappropriate, and the related debate as to how accident and emergency domains should be labelled.

Adverse events

Labels form a key part of communication systems in healthcare, with communication failures a common source of serious adverse events.

While the importance of labelling in packaging of medication and the proper marking of sites to prevent wrong-site surgery have been well documented, there are more subtle ways in which labelling may critically impact on patient safety.

“There are subtle ways in which labelling may impact on patient safety”

Font size matters – if the concentration of insulin is in larger font size than the dose, the doctor may prescribe on the basis of the concentration rather than the dose.

If the lower-case letter ‘l’ is not routinely written with a slight loop, it can be mistaken for the number 1 if the latter is not routinely written with a hook at the top, and the result can be harmful for patients, as happened in the case of the drug Lamictal, where the last ‘l’ was mistaken for ‘1’.

In the USA, 9/11 means 11 September, whereas in Britain it means the ninth of November. A simple policy of always writing months as words, not as numbers, could mean that dates of birth of patients and key dates for operations would not run the risk of getting confused.

There is wide variation in the format and legibility of wristbands worn as identification by patients, with a potential for patient safety errors.

Name game

It should be mandatory for the surname of patients to be printed in bold uppercase when typed, and uppercase when written. Thus, Miles James would be written as Miles JAMES, so that the patient may not be confused with a patient in the adjacent bed who might be called James MILES.

The popularity of the campaign initiated by the terminally ill cancer patient Dr Kate Granger, where staff are encouraged to introduce themselves, has put a focus on name badges, which studies have shown can be prone to deficiencies.

Labelling also applies to signage inside hospital buildings

Simple research could come up with font size, case and background that would be legible and readily understood, thus facilitating rapport between staff and patients.

Labelling also applies to signage inside hospital buildings and on hospital sites. It would seem logical to have the names of wards and departments within hospital lifts to help families and visitors to navigate, but this simple piece of environmental psychology is lacking in many hospitals.

Commercialisation and compassion

Similarly, ensuring visibility of photographs of staff in the entrance to hospital wards and departments is quite variable in its occurrence, even though improved patient satisfaction has been found when such measures are introduced.

The Thatcher years heralded the commercialisation of the NHS, and business terminology is now rife, with labels such as ‘chief executive’ and ‘director of operations’ taken for granted.

The acknowledged father of patient safety, Avedis Donabedian, shortly before he died, lamented – as have so many others – the commercialisation of healthcare and the introduction of business models. Commercialisation and compassion do not make great bedfellows, and we should have terminology that respects this fact.