PTCE: Institute for Safe Medication Practices’s (ISMP’s) List of Error-Prone Abbreviations, Symbols, and Dose Designations

The use of pharmacy abbreviations, acronyms, and symbols may be misinterpreted due to ambiguities, which could result in significant patient safety concerns. These errors are often reported to the Institute for Safe Medication Practices National Medication Errors Reporting Program (ISMP MERP). The ISMP maintains this voluntary practitioner error-reporting program to learn more about these errors and share information learned with the health care community.

Examples of these errors include those made when prescribing, transcribing, dispensing, and administering medications/vaccines.

The ISMP has argued that these abbreviations, acronyms, and symbols should be avoided in all medical communications, including written communications, telephone/verbal communications, computer-generated labels and storage bin labels, computer order entry screens, and medication administration records.

Examples of these dose designations, medication abbreviations, and symbols can be found in the following table.

The abbreviations, symbols, and dose designations in the table below were reported to ISMP through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been misinterpreted and involved in harmful or potentially harmful medication errors. These abbreviations, symbols, and dose designations should NEVER be used when communicating medical information verbally, electronically, and/or in handwritten applications. This includes internal communications; verbal, handwritten, or electronic prescriptions; handwritten and computer-generated medication labels; drug storage bin labels; medication administration records; and screens associated with pharmacy and prescriber computer order entry systems, automated dispensing cabinets, smart infusion pumps, and other medication-related technologies.

In the table, error-prone abbreviations, symbols, and dose designations that are included on The Joint Commission’s “Do Not Use” list (Information Management standard IM.0 .0 .01) are identified with a double asterisk (**) and must be included on an organization’s “Do Not Use” list. Error-prone abbreviations, symbols, and dose designations that are relevant mostly in handwritten communications of medication information are highlighted with a dagger (†).

Table. Error-Prone Abbreviations, Symbols, and Dose Designations

(open image in new window to view larger size)

While the abbreviations, symbols, and dose designations in the table should NEVER be used, not allowing the use of ANY abbreviations is exceedingly unlikely. Therefore, the person who uses an organization-approved abbreviation must take responsibility for making sure that it is properly interpreted. If an uncommon or ambiguous abbreviation is used, and it should be defined by the writer or sender. Where uncertainty exists, clarification with the person who used the abbreviation is required.