Practice Alert

Medication Errors From Inappropriate Abbreviations

One of the major causes of medication errors results from the use of potentially dangerous abbreviations and dose expressions. Symbols and abbreviations are frequently used to save time when writing prescriptions and documenting in patient records.

Examples of especially problematic abbreviations include “U” for units and “ug” for micrograms. Writing “U” can give the appearance of a zero. Using the abbreviation of “ug” rather than “mcg” has also been a source of errors when the handwritten symbol “u” resembles the letter “m”. Another frequent and dangerous occurrence is the inability to clearly distinguish a decimal point. The decimal point is sometimes not visible when orders are handwritten using trailing zeros or no leading zeros.

Examples of Correct and Incorrect use of Decimal points and Zeros

Correct	Incorrect
2. or 2	2.0

0.2	.2

Use of computerized order entry systems can reduce errors associated with illegible handwriting. Realizing that many health care organizations are unable to afford the new technologies, other risk reduction strategies are available. Suggestions include:

Develop a list of unacceptable abbreviations and symbols that is shared with all prescribers.
Develop a policy to ensure that medical staff refer to the list, and take steps to ensure compliance.
Establish a policy that if an unacceptable abbreviation or symbol is used, the prescription order is verified with the prescriber prior to its being filled.

This information is based upon the JCAHO Sentinel Event Alert, Issue 23, September, 2001.

For questions related to this alert, contact Education, Practice and Research: 518.782.9400, ext. 282