Download Dangerous Abbreviations

Policy Relationship: Clinical
General Patient Care: Standards of Patient Care
Effective Date: May 6, 2013
9.0
Section Number: 9.0
Subsection Number: 9.1.19P
Policy Number:
General Patient Care
9.1
Standards of Patient Care
9.1.19P Dangerous Abbreviations - Do Not Use Error Prone Abbreviations,
Symbols and Dose Designations
1.0
Purpose
The use of abbreviations and symbols can lead to misinterpretation with risk to patients,
health care providers and VIHA. The Institute for Safe Medication Practices (ISMP)
Canada has identified specific high risk abbreviations and symbols and these have been
incorporated into Accreditation Canada Required Organizational Practices (ROPs). This
policy is intended to ensure patient safety and compliance with Accreditation Canada
Standards, in medication management through safe and accurate communication of
medication orders between all members of the health care team.
2.0
Policy
Abbreviations, symbols, and dose designations prohibited for use by Accreditation
Canada as dangerous and identified by the Institute for Safe Medication Practices (ISMP)
Canada will not be used when communicating medication orders. These prohibited
abbreviations, symbols and dose designations and the required alternatives are listed in
section 3.0 (Definitions) below.
This policy applies to all forms of orders including but not limited to Clinical Order Sets
and Power Plans.
3.0
Definitions
“Do Not Use” Dangerous Abbreviations, Symbols and Dose Designations
Issuing Authority: VIHA Combined Quality Council
Date Issued: May 6, 2013
Date(s) Reviewed(r)/Revised(R):
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Do Not Use
Dangerous Abbreviations, Symbols and Dose Designations
The abbreviations, symbols, and dose designations found in this table have been reported as being frequently
misinterpreted and involved in harmful medication errors. They should NEVER be used when communicating
medication information.
Abbreviation
Intended Meaning
U
unit
IU
international unit
Abbreviations
for drug
names
QD
QOD
Every day
Every other day
OD
Every day
OS, OD, OU
Left eye, right eye, both
eyes
D/C
Discharge
cc
cubic centimetre
ISMP Canada July 2006
µg
microgram
Symbol
Intended Meaning
@
at
>
<
Problem
Mistaken for “0” (zero), “4” (four), or
cc.
Mistaken for “IV” (intravenous) or
“10” (ten).
Misinterpreted because of similar
abbreviations for multiple drugs;
e.g., MS, MSO4 (morphine
sulphate), MgSO4 (magnesium
sulphate) may be confused for one
another.
QD and QOD have been mistaken
for each other, or as ‘qid’. The Q
has also been misinterpreted as “2”
(two).
Mistaken for “right eye”
(OD = oculus dexter).
Correction
Use “unit”.
Use “unit”.
Do not abbreviate drug names.
Use “daily” and “every other
day”.
Use “daily”.
May be confused with one another.
Use “left eye”, “right eye” or
“both eyes”.
Interpreted as “discontinue
whatever medications follow”
(typically discharge medications).
Use “discharge”.
Mistaken for “u” (units).
Use “mL” or “millilitre”.
Mistaken for “mg” (milligram)
resulting in one thousand-fold
overdose.
Use “mcg”.
Potential Problem
Correction
Mistaken for “2” (two) or “5” (five).
Use “at”.
Greater than
Less than
Mistaken for “7”(seven) or the letter
“L” .
Confused with each other.
Use “greater than”/”more than”
or “less than”/”lower than”.
Dose
Designation
Intended Meaning
Potential Problem
Trailing zero
X.0 mg
Decimal point is overlooked
resulting in 10-fold dose error.
Never use a zero by itself after
a decimal point.
Use “X mg”.
Lack of
leading zero
. X mg
Decimal point is overlooked
resulting in 10-fold dose error.
Always use a zero before a
decimal point. Use “0.X mg”.
Correction
Adapted from ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 2006
Institute for Safe Medication
Practices Canada
Institut pour l’utilisation sécuritaire
des médicaments du Canada
Permission is granted to reproduce material for internal communications with proper attribution. Download from: www.ismp-canada.org/dangerousabbreviations.htm
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