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Stemming drug errors from abbreviations
Problem: Abbreviations and tions that have been incorrectly ation for the investigational drug CPX, being tested in cystic fibrosis, acronyms save time; they can interpreted. Abbreviations and acronyms are sounds similar to CTX, which is also lead to medication errors. Not all practitioners interpret abbrevi- routinely used to describe chemo- the abbreviation used for the ations uniformly, and, therefore, therapy protocols. This practice chemotherapy drug Cytoxan. Latin apothecary abbreviations the intended meaning is not al- often leads to confusion, as some protocols differ by only one or two are also prone to misinterpretation ways conveyed. Historically, medication errors letters. For example, the abbrevia- resulting from either a poorly have resulted from incorrect interpre- Table 1 tation of poorly Typed and written abbreviations for drugs written, ambiguIntended meaning Misinterpretation ous, or unfamil- Abbreviation/acronym zidovudine azathioprine iar abbreviations AZT Compazine chlorpromazine and acronyms— CPZ DPT diphtheria-pertussis-tetanus Demerol-Phenergan-Thorazine with poor penmanhydrocortisone hydrochlorothiazide ship the primary HCT hydrochlorothiazide hydrocortisone cause of these er- HCTZ MgSO4 magnesium sulfate morphine sulfate rors. Healthcare MSO morphine sulfate magnesium sulfate 4 practitioners are TAC triamcinolone tetracaine, Adrenalin, cocaine discovering, how- 5-ASA 5-aminosalicylic acid five tablets of aspirin ever, that typed abbreviations are Table 2 prone to misinterLatin apothecary abbreviations pretation as well. Intended meaning Misinterpretation On different occa- Abbreviation/acronym once daily right eye sions, an Rx with o.d. or OD three times a week three times daily the abbreviation TIW or tiw subcutaneous sublingual MTX has been in- SC every day q.i.d. or four times daily terpreted as metho- q.d. or QD Qhs at bedtime every hour trexate or mitoxanIU International units IV or intravenously trone. The Food & U Units misread as 0 (zero) Drug Administra- Per os orally os taken to mean “left eye” tion received one mcg microgram “mg” or milligram medication error report in August 2000 involving tion MIME refers to a chemothera- scripted Rx or an unfamiliar abthe misinterpretation of the abbre- py regimen comprised of mitogua- breviation. Tenfold insulin overviation DTO for a 13-day-old zone, ifosfamide, methotrexate, doses have resulted from the misinfant. The abbreviation DTO, or and etoposide. This is similar to interpretation of the abbreviation Deodorized Tincture of Opium, the MINE protocol, which consists U (for “units”) as a zero when has been incorrectly referred to as of mesna, ifosfamide, mitoxan- closely followed by a number in diluted tincture of opium, which trone, and etoposide. The abbrevi- written orders. In 1993, the FDA received a medication error report contains 1/25 the amount of about a patient who died because opium. Although the error was By corrected before the drug reached Alina Mahmud, R.Ph., Jerry Phillips, “20 U” of insulin was misinterpreted as 200 U. Another fatal the patient, this inadvertent misR.Ph., and Carol Holquist, R.Ph. accident occurred in 1995 when a take could have cost the patient prescription for “furosemide 40 her two-week-old life. Table 1 mg Q.D.” was misinterpreted as illustrates some drug abbrevia-
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furosemide 40 mg QID. Other examples of misinterpreted Latin apothecary abbreviations are listed in Table 2. Recommendations: The National Coordinating Council for Medication Error Reporting & Prevention (NCCMERP) encourages the avoidance of abbreviations in the prescribing of medications. Although it is more time-consuming, drug names, dosage units, and directions for use should be written clearly to minimize confusion. For example, doses in micrograms should always have the unit written out, because the abbreviation µg can easily be misread as mg, creating a 1000-fold overdose. If abbreviations are unavoidable, either healthcare practitioners should attempt to write neatly or institutions should implement measures to minimize misinterpretation of handwriting with the use of computerized physician order entry systems. Practitioners should also familiarize themselves with Latin apothecary abbreviations and most widely used acronyms so that only one meaning is understood. A handy reference book for practitioners is entitled 15,000 Conveniences at the Expense of Communications and Safety, which is authored by Neil Davis. This book lists 15,000 acronyms, symbols, and other medical abbreviations and 22,000 of their possible meanings to assist individuals in interpreting medically related communications.
Alina Mahmud, R.Ph., is team leader, Jerry Phillips, R.Ph., is acting director, and Carol Holquist, R.Ph., is deputy director, Division of Medication Errors & Technical Support, Office of Drug Safety, Food & Drug Administration.
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