MARCH 2002

AVOIDING MEDICATION ERRORS:

USING APPROVED MEDICAL ABBREVIATIONS

Using inappropriate medical abbreviations for drug names during the prescribing process has been identified as one of the factors that may increase the risk of causing a serious medication error. The following scenario demonstrates a mis-abbreviation drug example that has occurred at Kansas University Medical Center but fortunately, was recognized and did not result in the patient receiving the wrong medication.

A patient was admitted to general care nursing unit with the following medications prescribed upon admission,

Atarax 50 mg PO q 6-8 hr prn

Benadryl 25 g PO q 6hr

TAC 0.1% ointment to skin BID

Tylenol 650 mg q 4 hr prn

Mylanta 30 cc PO q 6 hr prn

The TAC order was interpreted as tetracaine-adrenalin-cocaine, but there was confusion as the pharmacy only stocked TAC gel not an ointment and the dosage regimen indicated for this product appeared inapproriate. When the prescriber was notified, it was determined that the drug intended for administration was triamcinolone.

A list of approved abbreviations at KUMC can be found in the front of the printed formulary or at the following url:

http://www2.kumc.edu/pharmacy/medabbreviations.htm

. Regulations for the use of abbreviations at Kansas University Medical Center have been approved by the Executive Committee of the Medical Staff include the following:

§ Only approved abbreviations have been approved for use in the body of a patient’s chart.

§ No abbreviations are permissible in either the summary nor on the admission and Diagnosis Form (Face Sheet), nor on the Physician’s Order Form

§ Also permitted are the recognized and acknowledged abbreviations or symbols of chemistry, physics, mathematics, biochemistry, pharmacology, biology and grammar.

§ Abbreviations for governmental agencies closely associated with medical social problems are acceptable but a legend is preferred because of relatively frequent changes of the name of agencies involved in medical social care.

§ All other abbreviations must be explained by a legend on each chart.

The Pharmacy and Therapeutics Committee will be working in conjunction with Medical Records to update the approved medical abbreviations listing in regards to drug name abbreviations.

Various medication safety groups, including JCAHO, have identified some abbreviations associated with misinterpretation and patient harm.

Here are a few abbreviations to avoid:

Abbreviation/ Dose Expression	Intended Meaning	Misinterpretation	Correction
cc	milliliter	Mistaken for “00”, two zeros when handwritten	Use “mL”
“º”	Hour(s), i.e. “q1º”	Mistaken for a zero when handwritten. i.e. every “10”	Use “Hr”
MgSo4	Magnesium Sulfate	Mistaken for Morphine Sulfate (MSO4)	Write out magnesium
MSO4	Morphine Sulfate	Mistaken for Magnesium Sulfate (MgSO4)	Write out morphine
ug, or μg	Micrograms	Mistaken for a zero when handwritten	Use “mcg”
sq	Subcutaneous	The “q” has been mistaken for “every”	Use “SQ”
SC	Subcutaneous	Mistaken for SL	Use “SQ”
“	Inch	Mistaken for “11”	Write out inch