ISMP List of Error-Prone Abbreviations, Symbols, and Dose ...

1 2021 - ISMPThe abbreviations , symbols , and dose designations inthe Tablebelow were reported to ISMP through theISMP National Medication Errors Reporting Program(ISMP MERP) and have been misinterpreted and involvedin harmful or potentially harmful medication abbreviations , symbols , and dose designationsshould NEVERbe used when communicating medicalinformation verbally, electronically, and/or in handwrittenapplications. This includes internal communications;verbal, handwritten, or electronic prescriptions; hand-written and computer-generated medication labels; drugstorage bin labels; medication administration records;and screens associated with pharmacy and prescribercomputer order entry systems, automated dispensingcabinets, smart infusion pumps, and other medication-related technologies.

2 In the Table, Error-Prone abbreviations , symbols , anddose designations that are included on The JointCommission s Do Not Use list (Information Manage-ment standard .0 .01) are identified with a doubleasterisk (**) and must be included on an organization s Do Not Use list. Error-Prone abbreviations , Symbols, and dose designations that are relevant mostly in hand-written communications of medication information arehighlighted with a dagger ( ).List continued on page 1 Institute for Safe Medication PracticesError-Prone Abbreviations, symbols , and DoseDesignations Intended MeaningMisinterpretationBest PracticeAbbreviations for Doses/Measurement Units cc Cubic centimetersMistaken as u (units)Use mLIU** International unit(s)Mistaken as IV (intravenous)or the number 10 Use unit(s) (International units can beexpressed as units alone)l ml Liter Milliliter Lowercase letter l mistakenas the number 1 Use L (UPPERCASE) for liter Use mL (lowercase m,UPPERCASE L)

3 For milliliter MM or M M or K MillionThousandMistaken as thousandMistaken as millionM has been used to abbreviateboth million and thousand(M is the Roman numeral forthousand)Use million Use thousandNg or ngNanogramMistaken as mgMistaken as nasogastricUse nanogram or nanogU or u** Unit(s)Mistaken as zero or thenumber 4, causing a 10-foldoverdose or greater ( , 4 Useen as 40 or 4u seen as 44)Mistaken as cc, leading toadministering volume insteadof units ( , 4u seen as 4cc)Use unit(s) g MicrogramMistaken as mgUse mcgAbbreviations for Route of AdministrationAD, AS, AU Right ear, left ear, each earMistaken as OD, OS, OU(right eye, left eye, each eye) Use right ear, left ear, or eachearINIntranasalMistaken as IM or IVUse NAS (all UPPERCASE letters)

4 Or intranasal ISMP List of Error-Prone abbreviations , symbols , and Dose abbreviations , symbols , and Dose Designations ** On The Joint Commission s Do Not Use list Relevant mostly in handwritten medication information 2021 - ISMPE rror-Prone Abbreviations, symbols , and DoseDesignations Intended MeaningMisinterpretationBest PracticeITIntrathecalMistaken as intratracheal,intratumor, intratympanic, orinhalation therapy Use intrathecalOD, OS, OURight eye, left eye, each eyeMistaken as AD, AS, AU(right ear, left ear, each ear)Use right eye, left eye, oreach eyePer osBy mouth, orallyThe os was mistaken as lefteye (OS, oculus sinister)Use PO, by mouth, or orallySC, SQ, sq, or sub q Subcutaneous(ly)SC and sc mistaken as SL orsl (sublingual)SQ mistaken as 5 every The q in sub q has beenmistaken as every Use SUBQ (all UPPERCASE letters, without spaces orperiods between letters) orsubcutaneous(ly)

5 abbreviations for Frequency/Instructions for UseHShsHalf-strengthAt bedtime, hours of sleepMistaken as bedtimeMistaken as half-strength Use half-strengthUse HS (all UPPERCASE letters) for bedtime or ODOnce dailyMistaken as right eye (OD,oculus dexter), leading to oralliquid medications administ-ered in the eyeUse , QD, , or qd** Every dayMistaken as , especiallyif the period after the q orthe tail of a handwritten q ismisunderstood as the letteriUse daily QhsNightly at bedtimeMistaken as qhr (every hour)Use nightly or HS for bedtimeQnNightly or at bedtimeMistaken as qh (every hour)Use nightly or HS for , QOD, , orqod**Every other dayMistaken as qd (daily) or qid(four times daily), especiallyif the o is poorly writtenUse every other dayq1d DailyMistaken as qid (four timesdaily)Use dailyq6PM, evening at 6 PMMistaken as every 6 hoursUse daily at 6 PM or 6 PM dailySSRISSIS liding scale regular insulinSliding scale insulinMistaken as selective-serotonin reuptake inhibitor Mistaken as Strong Solutionof Iodine (Lugol s)

6 Use sliding scale (insulin) TIW or tiwBIW or biw times a week times a weekMistaken as times a day ortwice in a weekMistaken as times a dayUse times weeklyUse times weeklyUD As directed (ut dictum) Mistaken as unit dose ( , anorder for dilTIAZem infusionUD was mistakenly administ-ered as a unit [bolus] dose)Use as directedList continued on page 2 Institute for Safe Medication PracticesList continued from page 1** On The Joint Commission s Do Not Use list Relevant mostly in handwritten medication information 2021 - ISMPE rror-Prone Abbreviations, symbols , and DoseDesignations Intended MeaningMisinterpretationBest PracticeMiscellaneous abbreviations Associated with Medication UseBBA BGBBaby boy A (twin) Baby girl B (twin)B in BBA mistaken as twin Brather than gender (boy)B at end of BGB mistaken asgender (boy)

7 Not twin B When assigning identifiers tonewborns, use the mother slast name, the baby s gender(boy or girl), and a distinguish-ing identifier for all multiples( , Smith girl A, Smith girl B)D/CDischarge or discontinuePremature discontinuation ofmedications when D/C(intended to mean discharge)on a medication list was mis-interpreted as discontinuedUse discharge and discon-tinue or stopIJInjectionMistaken as IV or intrajugularUse injectionOJOrange juiceMistaken as OD or OS (rightor left eye); drugs meant tobe diluted in orange juicemay be given in the eyeUse orange juicePeriod following abbrevia-tions ( , mg.)

8 , mL.) mg or mLUnnecessary period mis-taken as the number 1,especially if written poorlyUse mg, mL, etc., without aterminal periodDrug Name AbbreviationsTo prevent confusion, avoid abbreviating drug names entirely. Exceptions may be made for multi-ingredient drug formu-lations, including vitamins, when there are electronic drug name field space constraints; however, drug name abbreviationsshould NEVER be used for any medications on the ISMP List of High-Alert Medications(in Acute Care Settings[ ], Community/Ambulatory Settings [ 9], and Long-Term Care Settings[ 0]).

9 Examples of drug name abbreviations involved in serious medication errors include:Antiretroviral medications( , DOR, TAF, TDF)DOR: doravirineTAF: tenofovir alafenamideTDF: tenofovir disoproxilfumarateDOR: Dovato (dolutegravirand lamiVUDine)TAF: tenofovir disoproxilfumarateTDF: tenofovir alafenamideUse complete drug namesAPAP acetaminophenNot recognized as acetamino-phenUse complete drug nameARA AvidarabineMistaken as cytarabine ( ARAC )Use complete drug nameAT II and AT IIIAT II: angiotensin II(Giapreza)AT III: antithrombin III(Thrombate III)AT II (angiotensin II) mistakenas AT III (antithrombin III)AT III (antithrombin III) mis-taken as AT II (angiotensin II)Use complete drug namesAZTzidovudine (Retrovir)Mistaken as azithromycin,azaTHIO prine, or aztreonamUse complete drug nameCPZC ompazine (prochlorperazine)Mistaken as chlorproMAZINEUse complete drug nameDTOdiluted tincture of opium ordeodorized tincture of opium(Paregoric)

10 Mistaken as tincture ofopiumUse complete drug nameList continued on page 43 Institute for Safe Medication PracticesList continued from page ** On The Joint Commission s Do Not Use list Relevant mostly in handwritten medication information 2021 - ISMPE rror-Prone Abbreviations, symbols , and DoseDesignations Intended MeaningMisinterpretationBest PracticeHCThydrocortisoneMistaken as hydroCHLORO-thiazideUse complete drug nameHCTZ hydroCHLORO thiazideMistaken as hydrocortisone( , seen as HCT 50 mg)Use complete drug nameMgSO4**magnesium sulfateMistaken as morphine sulfateUse complete drug nameMS, MSO4** morphine sulfateMistaken as magnesium sulfateUse complete drug nameMTX methotrexateMistaken a