Download Dangerous Abbreviations and Decimal Use POLICY

Children's Hospital and Regional Medical Center
(Clinical Policy/Procedure: D )
Dangerous Abbreviations and Decimal Use
POLICY:
The specified abbreviations are not allowed in the medical record.
PURPOSE:
Abbrevations are not safe to use. The following abbreviations related to
medications have a high chance of harming our patients. These
abbreviations are prohibited in the entire medical record, including orders,
prescriptions, progress notes, flow-sheets, communications and other
documentation.
PROCEDURE:
I.
Children’s Hospital prohibits use of the following abbreviations:
Figure 1
Unacceptable
Abbreviations
Acceptable Use
Rationale
μg
Can look like milligrams.
MS, MSO4,
MgSO4
Spell out micrograms, or use
mcg
Spell out morphine or
magnesium sulfate
QD or
QOD
Spell out once daily or
every other day
Mistaken for each other. The period after
the Q can be mistaken for an I and the O
can be mistaken for I.
u for units
IU for International
Units
Naked Decimal
Write out the word unit or
units or international units
The handwritten U or u can look like a zero
or a six, leading to an overdose error.
Add zero before leading
decimal
Can be mistaken for a whole number.
.5mL
Trailing Zero
0.5mL
Avoid zero after decimal
when writing whole numbers
2
Potential for 10 fold error.
2.0
Morphine sulfate can be mistaken for
magnesium sulfate or magnesium sulfate
can be mistaken for morphine sulfate.
Exception: If a key or legend is provided on the same page, an otherwise unacceptable
abbreviation may be used on a typed Children’s document (e.g. clinical path or roadmap) but such
use is discouraged.
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Page 2: Clinical Policy/Procedure: Dangerous Abbreviations and Decimal Use
II.
III.
If the pharmacist encounters any other drug abbrevation which raises a concern for a
potential medication mix-up, they will call the prescriber to obtain clarification prior to
processing the order.
Appropriate Placement of Decimal:
A.
Trailing zeros may be used in non-medication related documentation when there is
a clear need to demonstrate level of precision, such as:
1.
Laboratory values
2.
Imaging study measurement of lesion sizes
3.
Catheter and therapeutic tube sizes
See also: Clincal P&P Medication Ordering and Transcription
Submitted by:
Helen Kurre, PharmD, MBA, Medication Safety Manager
Reviewed by:
Medical Records-Medical Informatics Committee (Mark DelBeccaro, MD,
Chair)
Quality Improvement Steering Committee (Pat Hagan, COO, Chair)
Pharmacy & Therapeutics Committee, May 2005 (Eric Harvey, PharmD and
Janet Englund,MD, Co-Chairs)
Revised by:
Patient Safety Communications Committee (Jill Langle, Chair)
Approved by Medical Executive Committee: 6/03, 12/03, 5/05
APPROVED BY:
Richard Molteni, MD
Vice President & Medical Director
ORIGINATED:
REVIEWED:
REVISED:
Susan Heath, RN, MN
Nurse Executive
4/03
12/03, 5/05, 4/06
Additional Key Words: Dangerous Abbreviations, Abbreviations, Trailing Zero, Naked Decimal, JCAHO Sentinel
Event Alert, Patient Safety, Unacceptable Abbreviations
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