Error-Prone Abbreviations


Elham Reshid and Hailemariam Shimelis

Medication errors are among the most common medical errors, harming at least 1.5 million people every year. The nature of medication use which comprises the complex processes from prescribing to therapeutic effects monitoring has contributed to these errors. The Institute for Safe Medication Practices (ISMP) has identified 10 key elements with the greatest influence on medication use including, drug labeling, packaging and nomenclature, noting that weaknesses in these can lead to medication errors.

Throughout healthcare, “shortcuts” such as abbreviations and symbols are often used to save time when communicating medication orders, especially in handwritten communication. However, some abbreviations, symbols and dose designations are frequently mis-interpreted and lead to mistakes that result in patient harm. One of the error-prone abbreviations most commonly reported is the abbreviation ‘U’ used to indicate ‘units’.

This abbreviation contributes to errors when it is misread as a zero (0) or as number 4. These errors often result in potential 10-fold or greater overdoses. Some abbreviations used to indicate the frequency of drug administration (e.g., QD and QOD) can be problematic as well, according to ISMP Medication Errors Reporting Program.

There was a case where an order was written for Digoxin 0.125 mg po QOD (every other day), but the medication was given QD (every day). The patient received two extra doses before the error was discovered. Even if some errors are manageable, they remain risky for drugs with low therapeutic drugs.

The ISMP and the U.S. Food and Drug Administration (FDA) have launched a national education campaign to help eliminate one of the most common but preventable sources of medication errors—the use of ambiguous medical abbreviations. One of the recommendations was that ISMP’s list of error-prone abbreviations, symbols, and dose designation be referenced whenever and wherever medical information is being communicated.

And, ISMP recommends never using these abbreviations when communicating medical information. And, please, to archive on the list of abbreviation never to be used, check on

Click for pdf here.


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