Rx Formulary and Handbook 2012-2013
University of Iowa Hospitals and Clinics
Peer Review Status: Internally Peer Reviewed
Last Reviewed: April 2012
Abbreviations are frequently used by health care providers to reduce the time it takes to communicate vital patient information. But in the course of patient care, several medical and drug name abbreviations have been mistaken or misinterpreted by other care providers, leading to errors that have caused significant patient harm. 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.1, 2, 3 These organizations and others have identified several abbreviations that have been associated with medical errors and should not be used in patient care.
To avoid a compromise in patient safety at the UIHC, the Pharmacy and Therapeutics Subcommittee and the Health Information Management Subcommittee have approved a list of dangerous medical abbreviations that may not be used. This list of dangerous abbreviations includes additional designations that have been associated with errors. The following medical abbreviations, designated as dangerous and not approved for use in written or printed communications associated with patient care, may not be used at UIHC:
|
Dangerous Medical Abbreviations |
||
|
Abbreviation |
Common Error |
Appropriate Action |
|
IU |
Mistaken as "IV" (intravenous) or 10 (ten). |
Write international unit(s) |
|
MgSO4 |
Misinterpreted as morphine sulfate, resulting in the wrong medication being administered. |
Write magnesium sulfate |
|
MS / MSO4 / MSO4 |
Misinterpreted as magnesium sulfate, resulting in the wrong medication being administered. |
Write morphine |
|
Q.D. / QD / q.d. / qd |
Mistaken for Q.O.D./ qod, resulting in an inappropriate dosing schedule. |
Write daily |
|
Q.O.D. / QOD / q.o.d. / qod |
Mistaken for Q.D./qd, resulting in an inappropriate dosing schedule. |
Write every other day |
|
T I W |
Misinterpreted as "three times a day" or "twice a week." |
Specify days of the week |
|
U / u |
Mistaken as a zero or a four (4), resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written. |
Write unit(s) |
|
µg |
Mistaken for "mg" (milligrams) when written, resulting in an overdose. |
Write microgram(s) or mcg |
Similarly, chemotherapy drug name abbreviations are never permitted to be used. The following abbreviations are particularly prone to misinterpretation if used in printed communications and must always be avoided:
|
Dangerous Chemotherapy Abbreviations |
|
|
Abbreviation |
Complete Drug Name To Be Written/Printed Out |
|
2-CDA |
Cladribine |
|
5-FU |
Fluorouracil |
|
6-MP |
Mercaptopurine |
|
CPT-11 |
Irinotecan |
|
IL-2 |
Aldesleukin |
|
VP-16 |
Etoposide |
|
CDDP |
Cisplatin |
|
MTX |
Methotrexate |
Decimal Numbers and Zeros
Medication doses may be misinterpreted when decimal numbers are not written out properly. The following actions should be taken to ensure that doses are written clearly and completely:
Prescribers will be notified to rewrite any orders using these dangerous abbreviations or order designations. Verbal orders will not be accepted to correct improperly written orders.
Please note that the list of dangerous medical abbreviations is continuously under review and may be revised at any time. The list of dangerous medical abbreviations is typically posted in those areas of the hospital where medication and treatment orders are written. View the current list of approved medical abbreviations.
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1"Medication Errors Related to Potentially Dangerous
Abbreviations," JCAHO Sentinel Event Alert, Issue 23, September 2001, at www.jcaho.org .
2ISMP 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).