Table 3. Error Prone Abbreviations, Dose Expressions, Symbols, Drug Abbreviations and Stems
Do Not Use |
Intended Meaning |
Potential Misinterpretation |
Use Instead |
Error Prone Abbreviations |
|||
μg¥ |
microgram |
milligram, resulting in a 1,000-fold overdose |
mcg or micrograms |
BT |
bedtime |
b.i.d. (twice daily) |
bedtime |
cc¥ |
cubic centimeters |
U or u (units) |
mL or milliliters |
D/C |
discontinue or discharge |
D/C followed by a list of medications could denote a list of medications patient should take upon discharge, or a list of medications patient should stop taking |
discontinue or discharge |
IJ |
injection |
IV (intravenous) or intrajugular |
injection |
HS |
half-strength |
at bedtime |
half-strength |
hs |
at bedtime or hour of sleep |
half-strength |
bedtime |
IU* |
International Unit |
IV (intravenous) or 10 (ten) |
International Unit |
MS* |
morphine sulfate or magnesium sulfate |
each other |
morphine sulfate or magnesium sulfate |
MSO4 and MgSO4* |
morphine sulfate and magnesium sulfate |
each other |
morphine sulfate or magnesium sulfate |
OD or o.d. |
once daily |
right eye (OD, oculus dexter), so that oral liquid medications may be administered to the eye |
daily |
Per os |
orally, by mouth |
left eye (OS, oculus sinister), so that oral liquid medications may be administered to the eye |
PO, orally or by mouth |
QD, Q.D., qd or q.d.* |
every day |
q.o.d (every other day); or q.i.d (four times daily), especially if period after the “q” or tail of the “q” is misread as an “i” |
daily |
qhs |
at bedtime |
qhr (every hour) |
at bedtime |
qn |
nightly |
qh (every hour) |
nightly |
QOD, Q.O.D., qod or q.o.d.* |
every other day |
q.d. (daily); or q.i.d. (four times daily), especially if the period after the “q” or the “o” is poorly written |
every other day |
q1d |
daily |
q.i.d (four times daily) |
daily |
q6PM, etc. |
every day at 6 PM |
every 6 hours |
6 PM daily or 6 PM nightly |
SC, SQ, sub q |
subcutaneous |
SC misinterpreted as SL (sublingual); SQ misinterpreted as 5 every; “q” in sub q misinterpreted as every |
subcut or subcutaneously |
TIW, T.I.W., tiw or t.i.w. |
three times a week |
3 times daily or twice a week |
3 times weekly |
U or u* |
unit |
0 (zero) or 4 (four), resulting in a 10-fold or greater overdose; cc, resulting in dose being given in volume instead of units |
unit |
1/d |
one daily |
t.i.d. (three times daily) |
1 daily |
Error Prone Dose Expressions |
|||
No leading zero before a decimal dose (e.g., .3 mg)* |
0.3 mg |
3 mg if decimal point is not seen |
Use zero before a decimal point when dose is less than 1 whole dose |
Trailing zero after decimal point (e.g., 5.0 mg)* |
5 mg |
50 mg if decimal point is not seen |
Do not use trailing zeros for whole number doses |
Drug name and dose written together without adequate space in between (especially for drug names ending with “L” e.g., benadryl50 mg) |
Benadryl 50 mg |
Benadryl 150 mg |
Ensure adequate space between drug name and dose |
Numerical dose and unit of measure written together without adequate space in between (e.g., 10mg, 100mL) |
10 mg 100 mL |
“m” is sometimes misinterpreted as one or two zeros, causing a 10- to 100-fold overdose |
Ensure adequate space between dose and unit of measure |
Large doses without properly inserted commas (e.g., 100000 units, 1000000 units) |
100,000 units 1,000,000 unites |
100000 has been misinterpreted as 10,000 or 1,000,000; 1000000 has been misinterpreted as 100,000 |
Use commas for dosing units at or above 1,000, or use words such as 1 “million” or 100 “thousand” |
Error Prone Symbols |
|||
Apothecary units¥ |
|
Unfamiliar to many practitioners and may be confused with metric units |
metric units |
>, <¥ |
greater than, less than |
each other; > misinterpreted as 7 (seven); < misinterpreted as letter L; <10 misinterpreted as 40 |
greater than or less than |
@¥ |
at |
2 (two) |
at |
& |
and |
2 (two) |
and |
+ |
plus or and |
4 (four) |
and or plus |
o |
hour |
zero (e.g., q6o read as q 60) |
hr, h or hour |
" |
second |
cc |
seconds |
/ (slash mark) |
per |
1 (one) |
“per” to separate doses |
x2d |
for two days or for two doses |
each other |
for 2 days or for 2 doses |
↑ |
increase |
1 (one) or letter T |
increase |
↓ |
decrease |
1 (one) |
decrease |
M |
million or thousand |
each other |
million or thousand |
K |
thousand, vitamin K or potassium |
each other |
thousand, vitamin K or potassium |
Error Prone Drug Name Abbreviations¥ and Drug Stems |
|
Misinterpreted due to similar abbreviations or stems for multiple drugs |
Use drug names in full |
DCN |
doxycycline |
Darvocet-N 100 |
doxycycline |
DPH |
diphenhydramine |
phenytoin, formerly called diphenylhydantoin |
diphenhydramine |
HCT |
hydrocortisone |
hydrochlorothiazide |
hydrocortisone |
HCTZ |
hydrochlorothiazide |
hydrocortisone |
hydrochlorothiazide |
MTX |
methotrexate |
mitoxantrone, Mustargen |
methotrexate |
TAC |
triamcinolone |
tetracaine, adrenalin, cocaine |
triamcinolone |
T3 |
Tylenol with codeine no. 3 |
liothyronine |
Tylenol with codeine no. 3 |
Norflox |
stem for norfloxacin |
Norflex |
norfloxacin |
IV Vanc |
stem for intravenous vancomycin |
Invanz |
IV vancomycin |
*These items are on the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) official “Do Not Use” list.
¥These items are on JCAHO’s additional abbreviations, acronyms and symbols list, for possible future inclusion in the official “Do Not Use” list.
Adapted from Cohen [8], and Joint Commission on the Accreditation of Healthcare Organizations [34].