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Eliminating Error-prone Abbreviations, Symbols, and Dose Designations.

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Presentation on theme: "Eliminating Error-prone Abbreviations, Symbols, and Dose Designations."— Presentation transcript:

1 Eliminating Error-prone Abbreviations, Symbols, and Dose Designations

2 2 The Problem Ambiguous medical notations are one of the most common and preventable causes of medication errors. Ambiguous medical notations are one of the most common and preventable causes of medication errors. Drug names, dosage units, and directions for use should be written clearly to minimize confusion. Drug names, dosage units, and directions for use should be written clearly to minimize confusion.

3 3 Consequences of Using Error-Prone Abbreviations n Misinterpretation may lead to mistakes that result in patient harm n Delay start of therapy due to time spent for clarification

4 4 Implement Do Not Use List The Institute for Safe Medication Practices (ISMP) and the Food and Drug Administration recommend that ISMPs list of error-prone abbreviations be considered whenever medical information is communicated. The Institute for Safe Medication Practices (ISMP) and the Food and Drug Administration recommend that ISMPs list of error-prone abbreviations be considered whenever medical information is communicated. Complete list is located at:

5 5 Consider All Communication Forms n Written orders n Internal communications n Telephone/verbal prescriptions n Computer-generated labels n Labels for drug storage bins n Medication administration records n Preprinted protocols n Pharmacy and prescriber computer order entry screens entry screens

6 6 Short List of Error-Prone Notations * The following notations should NEVER be used. NotationReasonInstead Use U Mistaken for 0, 4, ccunit IU Mistaken for IV or 10unit QDMistaken for QIDdaily *Comprises do not use list required for JCAHO accreditation

7 7 Short List of Error-Prone Notations Continued NotationReasonInstead Use QODMistaken for QID, QDevery other day Trailing zero Decimal point missedX mg (X.0 mg) Naked decimal Decimal point missed 0.X mg point (.X mg)

8 8 Short List of Error-Prone Notations Continued NotationReasonInstead Use MSCan mean morphinemorphine sulfate sulfate or magnesium sulfate MSO 4 and Can be confused withmorphine sulfate MgSO 4 each otheror magnesium sulfate ccMistaken for UmL

9 9 Short List of Error-Prone Notations Continued NotationReasonInstead Use Drug name Mistaken for other drugs Complete abbreviationsor notationsdrug name (especially those ending in l) > or or

10 Mistaken for 2 at & Mistaken for 2 and / Mistaken for 1 per rather than a slash mark + Mistaken for 4and Short List of Error-Prone Notations Continued NotationReasonInstead Use

11 11 NotationReasonInstead Use AD, AS, AUMistaken for OD, OS, OUright ear, left ear, or each ear OD, OS, OUMistaken for AD, AS, AUright eye, left eye, or each eye D/C, dc, d/cMisinterpreted as discharge or discontinued when discontinued followed by list of medications Short List of Error-Prone Notations Continued

12 12 Other Good Practices n Drug name abbreviations can easily be confused. Always write out complete drug name. n Apothecary units are unfamiliar to many practitioners. Always use metric units.

13 13 Examples Intended dose of 4 units in patient history interpreted as 44 units. U should be written out as unit. Intended dose of 4 units in patient history interpreted as 44 units. U should be written out as unit.

14 14 Examples Intended dose of.4 mg interpreted as 4 mg from medication order. Should be written as 0.4 mg. Intended dose of.4 mg interpreted as 4 mg from medication order. Should be written as 0.4 mg.

15 15 Examples Potassium chloride QD in medication order interpreted as QID. Should be written as daily.

16 16 Examples Intended recommendation of less than 10 was interpreted as 4. < should be written out as less than.

17 17 Examples QD in advertisement should be written out as daily. QD in advertisement should be written out as daily.

18 18 Examples U in prominent professional journal article should be written out as unit. U in prominent professional journal article should be written out as unit.

19 19 Do Not Use Error-Prone Abbreviations Even in Print n May still be confused n Perpetuates the impression that they are acceptable n May be copied into written orders

20 20 Recommendations for Healthcare Professionals n Avoid ambiguous abbreviations in written orders, computer- generated labels, medication administration records, storage bins/shelf labels, and preprinted protocols. n Work with computer software vendors to make changes in electronic order entry programs. n Provide examples when educating staff on how using error-prone abbreviations have led to serious patient harm. n Provide staff with ISMPs list of error-prone abbreviations. n Introduce healthcare students to the list of error-prone abbreviations.

21 21 Recommendations for Pharmaceutical Industry n Review existing drug labeling and packaging as well as new drug applications for use of error-prone abbreviations. n Eradicate use of ambiguous abbreviations in product advertising (both in graphics and text). n Check for error-prone abbreviations in all communications vehicles, including slides, promotional kits, and sales staff training materials. n Include ISMPs list in corporate editorial style guidelines. n Incorporate list into software and medical device design.

22 22 Recommendations for Medical Communications/Publishing Professionals n Make do not use list of notations as part of publishing style manuals and internal style guides for clinical writing. n Add the list of error-prone abbreviations to instructions for journal authors. n Review all internal and external communications products for ambiguous abbreviations. n Eliminate error-prone abbreviations in company-wide educational and training sessions.

23 23 Other Resources For more information and tools to help promote safe practices, visit: For more information and tools to help promote safe practices, visit: or


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