Rx Update: January 2003

Avoid Using These Dangerous Medical Abbreviations

Mary Ross, R.Ph., M.B.A., Joan Murhammer, R.Ph., Kevin Bebout, R. Ph.
First Published: January 2003
Peer Review Status: Internally Reviewed

Identifying ways to reduce medical errors continues to be a priority for healthcare organizations. One of the major causes of medication errors is the ongoing use of potentially dangerous abbreviations and dose designations. This problem has been extensively reviewed by several national safety organizations, including the Institute for Safe Medication Practices (ISMP), the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).1,2,3

Recently, JCAHO presented a list of Patient Safety Goals for 2003. Goal 2 on this list states:

"Improve the effectiveness of communication among caregivers."

To enhance the safety of communications, the JCAHO has recommended that healthcare organizations standardize any abbreviations, acronyms and symbols used throughout the organization and develop a list of abbreviations, acronyms and symbols that should not be used.1 Subsequently, the University of Iowa Hospitals and Clinics has identified several abbreviations that have been associated with unclear communications and could lead to medication errors. These medical abbreviations designated as dangerous and not approved for use are:

 

Dangerous Medical Abbeviations
Abbreviation
Intended meaning
Common Error
AAOC
Antacid of choice

Ambiguous. Requires other caregivers to determine what prescriber intended. May lead to the unintended administration of large amounts of magnesium, aluminum, or calcium.

LOC
Laxative of choice

Ambiguous. Requires other caregivers to determine what prescriber intended. May lead to the unintended administration of large amounts of sodium or magnesium

TIW
Three times a week

Misinterpreted as "three times a day" or "twice a week."

U
Unit / Units

Mistaken as a zero or a four (4) resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written.

µg
Micrograms

Mistaken for "mg" (milligrams) when written, resulting in an overdose.

Because of the safety concerns outlined above, the Pharmacy and Therapeutics Subcommittee and the Health Information Management Subcommittee have approved the deletion of these abbreviations from the UIHC's list of Approved Medical Abbreviations. Prescribers and other clinicians should write out complete words when ordering medication or other treatments designated in these ways. Prescribers will be notified to clarify orders using these dangerous abbreviations.

  1. "Medication Errors Related to Potentially Dangerous Abbreviations," JCAHO Sentinel Event Alert, Issue 23, September 2001, at www.jcaho.org.
  2. ISMP Medication Safety Alert!, May 2, 2001, www.ismp.org.
  3. "Recommendations to Correct Error-Prone Aspects of Prescription Writing," NCCMERP Council Recommendation, adopted Sept. 4, 1996, at www.nccmerp.org (under Council Recommendations).
  4. http://www.jcaho.org/

Title Page