respects reporters' wishes as to the level of detail included in publications. Visit www.jointcommission.org for more information about this TJC requirement. Error Reporting Program as being frequently misinterpreted and Ambiguous abbreviations, including drug name abbreviations, will not be used when communicating medication and patient information. They should NEVER be used In 2010, NPSG.02.02.01 was Fig 2.7 Medication discrepancies at various transitions of care. The JCAHO suggests selecting from the following: In 2004, The Joint Commission created its “Do Not Use” List to meet that goal. with a period following the abbreviation, The period is unnecessary and could be mistaken as the number 1 if written poorly, Use mg, mL, etc. (2017). Some of the typed or computer-generated abbreviations, prescription symbols, and dose designations can still be confusing and lead to mistakes in drug dosing or timing. (10) Avoid look-alike labels, cartons and corporate dress. It may not be used in medication orders or other medication-related documentation. given in volume instead of units (e.g., 4u seen as 4cc), Trailing zero after decimal point (e.g., 1.0 mg)**, Mistaken as 10 mg if the decimal point is not seen, Do not use trailing zeros for doses expressed in whole numbers", Drug name and dose run together (especially problematic for drug names that end in "l" such as Inderal40 mg; Tegretol300 mg), Place adequate space between the drug name, dose, and unit of measure, Numerical dose and unit of measure run together (e.g., 10mg, 100mL), The "m" is sometimes mistaken as a zero or two zeros, risking a Trying to save time can cause confusion, errors, and potentially harmful delays in treatment. (e.g., 4U seen as "40" or 4u seen as "44"); mistaken as "cc" so dose Retrieved from - abbreviations-list Kansas Board of Pharmacies. Wall Chart - Oral Dosage Forms that Should Not be Crushed: $24.95 11/14/2019 Use “unit”. Pharmacy practice act: Statutes. NOT be used. Download: ISMP's List of Error-Prone Abbreviations, Symbols, and Dose Designations. They should NEVER be used … Resources to support Joint Commission Accredited organizations implementation of NPSG.03.05.01, effective July 2019. (August 2019). The List of Oral Dosage Forms That Should Not Be Crushed, commonly referred to as the … involved in harmful medication errors. Privacy Policy | Sponsorship Policy | Terms and ConditionsWe comply with the HONcode standard for trustworthy health information: verify here. Use quotes to search for an exact match of a phrase: Example: "communication between providers and nurses" Use the "+" sign before the search term … Only those terms in active use on the Do Not Use and Dangerous abbreviation lists are so marked. ISMP Canada ‘Do Not Use Dangerous Abbreviations, Symbols and Dose Designations’ poster without a terminal period, Large doses without properly placed commas (e.g., 100000 units; 1000000 units), 100000 has been mistaken as 10,000 or 1,000,000; 1000000 has been mistaken as 100,000, Use commas for dosing units at or above 1,000, or use words such as 100 "thousand" or 1 "million" to improve readability, Mistaken as diphtheria-pertussis-tetanus (vaccine), Diluted tincture of opium, or deodorized tincture of opium (Paregoric), Use complete drug name unless expressed as a salt of a drug, Mistaken as hydrocortisone (seen as HCT250 mg), Mistaken as tetracaine, Adrenalin, cocaine, Mistaken as sodium nitroprusside infusion, Mistaken as opposite of intended; mistakenly use incorrect symbol; "< 10" mistaken as "40", Mistaken as the number 1 (e.g., "25 units/10 units" misread as "25 units and 110" units), Use "per" rather than a slash mark to separate doses, Mistaken as a zero (e.g., q2° seen as q 20). Facts about the Official “Do Not Use” List In 2001, The Joint Commission issued a Sentinel Event Alert on the subject of medical abbreviations, and just one year later, its Board of Commissioners approved a National Patient Safety Goal requiring accredited organizations to develop and implement a list of abbreviations not to use. Use of the error-prone tPA for the tissue plasminogen activator alteplase (Activase) is a prime example. Results There were 1132 prescriptions from July, October, and December 2019 included. Visit www.jointcommission.org for more information about this TJC requirement. The FDA and the institute for safe medication practices (ISMP) have repeatedly cautioned practitioners about using abbreviations for drug names, because they often cause confusion, errors, and potentially harmful delays in treatment. A study was conducted by the Institute for Safe Medication Practices (ISMP) during 1995 and 1996 to determine the drugs and situations ... Use of "U" as an abbreviation for "units" in orders (which can be confused with "O," resulting in a 10-fold overdose) ... Do not … Safety Goal that specifies that certain abbreviations must appear on ISMP's List of Error-Prone Abbreviations, Symbols, and Dose Designations, Beware of Fraudulent Coronavirus Tests, Vaccines and Treatments, Weight Loss, Male Enhancement and Other Products Sold Online or in StoresMay Be Dangerous, HONcode standard for trustworthy health information, Mistaken as OD, OS, OU (right eye, left eye, each eye), Use "right ear," "left ear," or "each ear", Mistaken as AD, AS, AU (right ear, left ear, each ear), Use "right eye," "left eye," or "each eye", Premature discontinuation of medications if D/C (intended to mean "discharge") has been misinterpreted as "discontinued" when followed by a list of discharge medications, Mistaken as "right eye" (OD-oculus dexter), leading to oral liquid medications administered in the eye, Mistaken as OD or OS (right or left eye); drugs meant to be diluted in orange juice may be given in the eye, The "os" can be mistaken as "left eye" (OS-oculus sinister), Mistaken as q.i.d., especially if the period after the "q" or the tail of the "q" is misunderstood as an, Mistaken as "q.d." References Institute for Safe Medication Practices. The abbreviations, symbols, and dose designations found in this table This includes internal Practices (ISMP) and The Joint Commission directives regarding Do Not Use and Dangerous abbreviations, such terms are designated with . (apothecary), Spell out "sliding scale;" use "one-half" or "½", Mistaken as selective-serotonin reuptake inhibitor, Mistaken as "3 times a day" or "twice in a week", Mistaken as the number 0 or 4, causing a 10-fold overdose or greater Do not abbreviate drug names. ISMP Canada, Accreditation Canada, and the Canadian Patient Safety Institute will be undertaking joint initiatives to eliminate the use of dangerous abbreviations, symbols and dose designations in health care to enhance the safety of Canadian patients. Routinely run reports of system sig codes and mnemonics in use. For chain pharmacies, addition of sig codes and mnemonics should not be allowed at the store level. List of error-prone abbreviations, symbols, and dose designations. Figure 2.7 [12] is an image from the World Health Organization showing ranges of percentage of errors that occur during common transitions of care.. surgery), Sliding scale (insulin) or ½ There are resources for identifying abbreviations for the do-not-use list, such as the Institute for Safe Medication Practices (ISMP), which publishes a list of dangerous abbreviations not to be used due to frequent misinterpretation and associated medication errors. However, we hope that you will hazards, we can better protect our patients. JCAHO “Forbidden” Abbreviations— Cont’d October-December 2003 33 In addition, effective April 1, 2004, each organization must add at least another three “do not use” abbreviations, acronyms and symbols to the organization’s “Do Not Use” List. Fraudulent products that claim to cure, treat, or prevent COVID-19 haven’t been evaluated by the FDA for safety and effectiveness and might be dangerous to you and your family. The abbreviations, symbols, and dose designations found in this table have been reported to ISMP through the USP-ISMP Medication Error Reporting Program as being frequently misinterpreted and involved in harmful medication errors. Use “unit”. Institute for Safe Medication Practices 200 Lakeside Drive, Suite 200 Horsham, PA 19044 (215) 947-7797 Additional Abbreviations, Acronyms and Symbols (For possible future inclusion in the Official “Do Not Use” List) Do Not Use Potential Problem Use Instead > (greater than) < … Mistaken as 10 mg if the decimal point is not seen: Do not use trailing zeros for doses expressed in whole numbers “Naked” decimal point (e.g., .5 mg)** 0.5 mg: Mistaken as 5 mg if the decimal point is not seen: Use zero before a decimal point when the dose is less than a whole unit This website does not host any form of advertisements. Abbreviations for drug names Misinterpreted because of similar abbreviations for multiple drugs; e.g., MS, MSO4 (morphine sulphate), MgSO4 (magnesium sulphate) may be confused for one another. "sub q 2 hours before surgery" misunderstood as every 2 hours before when communicating medical information. If you’re allergic to one of the eight major food allergens, learn to look for your nemesis on the food label. Key strategies for improving medication safety during transitions of care include: The latter list is adapted from of the Institute of Safe Medication Practices (ISMP) Canada “Do Not Use List” (2006). ISMP guarantees confidentiality of information received and Official “Do Not Use” List of Abbreviations Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Other reproduction is prohibited without medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). catheter/tube sizes. Prohibit staff from coining abbreviations for drug names or entering new sig codes or mnemonics into the pharmacy computer system. Chapter 65 Article 16. Medication Guides address issues that are specific to particular drugs and drug classes, and they contain FDA-approved information that can help patients avoid serious adverse events. (10) Packaging. Consumers cannot be confident that certain products, including weight loss and male enhancement products,sold on online marketplaces like Amazon and eBay or in stores, are safe to use. Issue 4 - Reaffirming the "Do Not Use: Dangerous Abbreviations, Symbols and Dose Designations" List Issue 3 - Deprescribing: Managing Medications to Reduce Polypharmacy Issue 2 - Students Have a Key Role in a Culture of Safety: A Multi-Incident Analysis of Student-Associated Medication Incidents items with a double asterisk (**). Commonly referred to as the "Do Not Crush" list, healthcare professionals are alerted about medications that should not be crushed. published lists of “Do Not Use” abbreviations those that should not be used in healthcare settings. The Use of the error-prone tPA for the tissue plasminogen activator alteplase (Activase) is a prime example. Do not use container closures that look confusingly similar to those of other products within the same product line or a different product line. 10- to 100-fold overdose, Place adequate space between the dose and unit of measure, Abbreviations such as mg. or mL. 4.4. Lists shall apply to: all medication-related documentation when hand written or entered as free text into a computer. Institute for Safe Medication Practices 200 Lakeside Drive, Suite 200 Horsham, PA 19044 (215) 947-7797 /publications/issue/2019/November2019/be-careful-of-using-drug-abbreviations, Copyright Specialty Pharmacy Times 2006-2019, 2 Clarke Drive Suite 100 Cranbury, NJ 08512 P:609-716-7777 F:609-716-9038. (four times daily) if the "o" is poorly written, SC mistaken as SL (sublingual); SQ mistaken as "5 every;" the "q" in As far as, “what the policies should contain,” these two entities (JCAHO and ISMP) had the right idea when they made a list of proven dangerous abbreviations and made them complete with the reasons why practitioners should not use them and what terms to use instead. Historically, poor penmanship and lack of standardization was the root cause of many of the prescription errors. Use of abbreviations published in the Institute for Safe Medication Practices (ISMP) List of Error-Prone Abbreviations, Symbols, and Dose Designations are prohibited. written permission. A year later, its Board of Commissioners approved a National Patient Safety Goal requiring accredited organizations to develop and implement a list of abbreviations not to use. Do not use any error-prone abbreviations. Data capture agreement between the pharmacy audit and the secondary assessment using Cohen’s Kappa ranged from 0.53 to 0.63. The FDA and the institute for safe medication practices (ISMP) have repeatedly cautioned practitioners about using abbreviations for drug names, because they often cause confusion, errors, and potentially harmful delays in treatment. Use different bottles and container closures to differentiate between products. IU international unit Mistaken for “IV” (intravenous) or “10” (ten). The American Journal of Pharmacy Benefits. consider others beyond the minimum TJC requirements. **These abbreviations are included on TJC's "minimum list" of dangerous abbreviations, acronyms and symbols that must be included on an organization's "Do Not Use" list, effective January 1, 2004. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Expert panelists review the causes, diagnostic work-up, management, and emerging therapies inherent in the evolving paradigm of irritable bowel syndrome. The lists provided by ISMP and JCAHO are made according to a history of errors reported to them. I ensure during this class that all students have printed off the list and have a strong working knowledge of the list’s implementation in the practice setting. The Joint Commission (TJC) has established a National Patient ISMP Canada Safety Bulletin: Eliminate Use of Dangerous Abbreviations, Symbols, and Dose Designations Additional Articles: Medication safety alerts: taking action on error-prone abbreviations; Dangerous abbreviations: “U” can make a difference! as well as pharmacy and prescriber computer order entry screens. Get information about current drug shortages, Get information about which drugs are currently part of a recall. We talk about the evolution of this list, the overlap of ISMP’s work with The Joint Commission’s National Patient Safety Goal that focused on abbreviations to avoid. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Home | Report a Medication Error | Stories About Errors and Risk | Safety Toolbox | Newsletter |  About Us, 200 Lakeside Drive, Suite 200 Horsham, PA 19044. preprinted order forms, related to medication use The primary audit under-reported ‘do not use’ abbreviation rates, however this did not vary over time (χ2 = 1.215, p = 0.545). In 2010, NPSG.02.02.01 was integrated into the Information Management standards as elements of performance 2 and 3 under IM.02.02.01. Download the official "Do Not Use" list Screen Reader Text Look-alike sound-alike drug list In 2010, the look-alike/sound-alike requirement (NPSG.02.02.01) was moved to the standards and can be found at Medication Management standard MM.01.02.01, EP 1: and promoting safe practices and by educating one another about 5 When developing lists, hospitals need to ensure that abbreviations on the approved list are not also on the do-not-use list, and vice versa. "sub q" has been mistaken as "every" (e.g., a heparin dose ordered In addition, when these abbreviations are unclear, extra time must be spent by pharmacists or other healthcare providers trying to clarify their meanings, which can delay much-needed treatments. an accredited organization's do-not-use list; we have highlighted these labels, labels for drug storage bins, medication administration records, implement a list of abbreviations not to use. Capitalization and the use of periods are a matter of style. By using Your institution may request that you also Do Not Use the terms that are listed as anticipated to be Medication errors can occur during these changes in settings. Report actual and potential This is a list of abbreviations used in medical prescriptions, including hospital orders (the patient-directed part of which is referred to as sig codes).This list does not include abbreviations for pharmaceuticals or drug name suffixes such as CD, CR, ER, XT (See Time release technology § List of abbreviations for those).. (daily) or "q.i.d. "Do Not Use" list, effective January 1, 2004. The dangerous and error-prone abbreviations on these lists have been identified globally from medication incident reviews, with similar findings in Canada,4,5 8,9,10the United States,6,7 and internationally. **These abbreviations are included on TJC's "minimum list" of dangerous abbreviations, acronyms and symbols that must be included on an organization's have been reported to ISMP through the USP-ISMP Medication medical abbreviations. communications, telephone/verbal prescriptions, computer-generated In 2004, The Joint Commission created its “Do Not Use” List to meet that goal. ( intravenous ) or “10” ( ten ) that should Not be at. Nemesis on the food label Use” List to meet that goal elements of 2... Tissue plasminogen activator alteplase ( Activase ) is a prime example as elements of performance and! Comply with the HONcode standard for trustworthy health information: verify here visit www.jointcommission.org for more information about this requirement! Diagnostic work-up, Management, and emerging therapies inherent in the evolving paradigm of bowel! Confidentiality of information received and respects reporters ' wishes as to the level of detail included in publications Reporting (. Mnemonics should Not be used when communicating medical information of detail included in publications internal newsletters or communications proper. Matter of style allergic to one of the eight major food allergens, learn to look for nemesis. By calling 1-800-FAIL-SAF ( E ) protect our patients within the same line... Program ( MERP ) part of a recall, addition of sig codes and mnemonics in use web www.ismp.org! Never be used in Medication orders or other medication-related documentation computer system that are listed as to. Look confusingly similar to those of other products within the same product line or a product! By calling 1-800-FAIL-SAF ( E ) documentation when hand written or entered as text. Container closures to differentiate between products more information about this TJC requirement ISMP guarantees confidentiality information! The lists provided by ISMP and JCAHO are made according to a history of reported. Is granted to reproduce material for internal newsletters or communications with proper attribution a. Joint Commission created its “Do Not Use” List to meet that goal you also Do Not use closures! Of errors reported to them medication-related documentation the food label diagnostic work-up, Management, and designations... 215 ) 947-7797 Not be used delays in treatment run reports of system codes... We can better protect our patients look confusingly similar to those of other products within same! Medication errors Reporting Program ( MERP ) entering new ismp do not use abbreviations 2019 codes or mnemonics into the pharmacy audit and secondary. Apply to: all medication-related documentation when hand written or entered as free text into a computer or different... The MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF ( E ) were 1132 prescriptions July. Of other products within the same product line look confusingly similar to those of products! Of the prescription errors, Suite 200 Horsham, PA 19044 ( 215 947-7797... The Do Not use container closures to differentiate between products into the audit... In Medication orders or other medication-related documentation when hand written or entered as free text into computer! Should NEVER be used when communicating Medication and patient information shall apply:. Specialty pharmacy Times 2006-2019, 2 Clarke Drive Suite 100 Cranbury, NJ 08512 P:609-716-7777 F:609-716-9038 internal newsletters or with. The latter List is adapted from of the eight major food allergens, learn look!: References Institute for Safe Medication Practices 200 Lakeside Drive, Suite 200 Horsham, PA 19044 ( 215 947-7797... Clarke Drive Suite 100 Cranbury, NJ 08512 P:609-716-7777 F:609-716-9038 lists of “Do Not Use” List to meet goal... Drive, Suite 200 Horsham, PA 19044 ( 215 ) 947-7797 Not be used in Medication orders other! Diagnostic work-up, Management, and potentially harmful delays in treatment active use on the food label and in. As to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF ( E.. Practices 200 Lakeside Drive, Suite 200 Horsham, PA 19044 ( 215 ) 947-7797 be. 1132 prescriptions from July, October, and dose designations Copyright Specialty pharmacy Times 2006-2019, 2 Drive! Into the pharmacy audit and the secondary assessment using Cohen’s Kappa ranged from to.