Dangerous Abbreviations
Health practitioners, authors, and editors must excercise due diligence in creating an abbreviation or they may cause situations similar to the ones shown below. Another possibility is not to abbreviate the phrase.
Note: Subscribers will have access to the following information:
MedAbbrev's Do Not Use List
This table was last updated in November 2023.
Healthcare organizations are directed by the Joint Commission not to use certain abbreviations and dose designations. In Table 1 below, these are shown in red.
If you are a facility who has a multi-user site license for this website, you may show your own "Do Not Use" list to your users. Contact us.
This list shown below (Table 1) is partially based on The Institute For Safe Medication Practices list of Error-prone Abbreviations (ISMP.org)
Table 1. Dangerous abbreviations and dosage designations
| Problem Term | Intended Meaning | Reason for Problem(s) | Suggested Remedy |
|---|---|---|---|
| AU | both ears | Read as OU (both eyes) or not understood | Use "both ears" |
| cc for expressing liquid measurements | cubic centimeter (same as milliliter [mL]) | Read as u (unit) or 00 | Use "mL" |
| D/C | discharge | Interpreted as discontinue medications resulting in premature discontinuance of current medication | Use "discharge" |
| IN | intranasal | Read as IV or IM or heard as IM | Use "intranasal" "nasally" or use "NAS" if limited by computer space allotted |
| IU | International unit | Misread as IV (intravenous); The I is read as a one (6 IU is read as 61 units) | Use "units" rather than international units, or spell out international units, using a lowercase i |
| IT | Intrathecal Intratracheal Intratumor Intratympanic Inhalation therapy |
The intended route of administration can be misinterpreted | Spell out these terms |
| MS | morphine sulfate | Not understood or misunderstood | Spell out these morphine sulfate |
| MSO4 | magnesium sulfate | Not understood or misunderstood | Spell out-magnesium sulfate |
| OD | once daily | Interpreted as right eye | Use "once daily" |
| OJ | Orange juice | Read as OS (left eye) or OD (right eye) | Use "orange juice" |
| QOD or qod | every other day | Interpreted as meaning "every once a day" or read as q.i.d. (four times daily) | Use "every other day" |
| QD or qd | once daily | Read or interpreted as q.i.d. (four times daily) | Use "once daily" |
| q.n. | every night | Read as every hour | Use "once daily at night" |
| q HS | every night | Read as every hour | Use "once daily at night" |
| μg | microgram | When handwritten, misread as mg | Use "mcg" |
| sq or sub q | subcutaneous | The q is read as every | Use "subcut" |
| ss | sliding scale or 1/2 | Read as the numbers 55 and 1/2 | Spell out "sliding scale" or "1/2" |
| sHTN |
secondary hypertension |
The severity of the hypertension can be misinterpreted | Use HTN, but spell out the specific type (e.g., systolic, secondary) instead of using the letter s |
| T/d (with a dot over the T) | one per day | Interpreted as t.i.d. (three times daily) | Use "one per day" |
| T1D | type 1 diabetes (mellitus) | Read as TID (three times daily) | Use DM-1 |
| T1DM | type 1 diabetes (mellitus) | Read as TIDM (three times daily with meals) | Use DM-1 |
| TIW | three times a week | Interpreted as T/W (Tuesday & Wednesday); as twice a week; as t.i.d. (three times daily) | Use "three times a week" |
| U | unit | When handwritten, read as 0, 4, 6, or cc | Use "unit" |
| Apothecary system of measure (grains, minims, and drams) | Units of measure | Not understood or misunderstood | Use the metric system (mg, g, mL) |
| Chemical symbols | Drug names or laboratory tests | Not understood or misunderstood | Use full name except for Na, Ca, O2, K, Cl, KCl and HCl |
| Such as MgSO4 | magnesium sulfate | Not understood or misunderstood; may be read as morphine sulfate | Spell out magnesium sulfate |
| Uncommon Latin words or phrases such as - per os | By mouth | Not understood or misunderstood | Use by mouth, orally, or PO |
| ss | 1/2 | Use "1/2" or "one half" | |
| UD | As directed | Use "as directed" | |
| Lettered abbreviations for drug names or drug protocols | Drug names or drug protocols | Not understood or misunderstood | Use generic and trade name(s). Follow policy for use of protocol names in your facility. |
| / (a slash mark) | with, and, or per | Read as one when followed by a number | Use "and", "with" or "per" |
| Roman numerals | Numbers | Not understood or misunderstood (iv read as intravenous rather than 4; iii, X, L, and C, not understood) | Use Arabic numerals (4, 3, 10, 50 100, etc.) |
| > and < | "greater than" or "less than" | Not understood or the meaning is reversed. Also a poorly written > (greater than) can be mistaken for the number 7. | Use "greater than" or "less than" |
| Drug name and dosage not separated by a space | Inderal 40 mg | Inderal40 mg misread as Inderal 140 mg | Always leave a space between a drug name, dose, and unit of measure |
| Trailing zeros; 1.0 mg | 1 mg | When handwritten decimal point is not seen; read as 10 mg causing a tenfold overdose | Omit the zero; Use 1 mg (see note below) |
| Naked decimal point; .5 mL | 0.5 mL | When handwritten decimal point is not seen; read as 5 mL causing a tenfold overdose | Add a zero; 0.5 mL |
| Abbreviated drug names | A drug name | Misinterpreted or not recognized | Use generic or brand name |
| Slang (this includes unique abbreviations and symbols used in texting which would not be understood be all) | communication | can be offensive, insensitive, or not understood | Do Not Use slang in verbal or written communications |
Exception: A trailing zero may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may NOT be used in medication orders or other medication-related documentation.
Letters in Abbreviations That Should Be Used with Care
The abbreviation B for breast, brain, bone, or bladder, ex:
BCa = breast cancer; brain cancer; bone cancer; bladder cancer
The abbreviation L for liver or lung, ex:
LT = liver transplantation; lung transplantation
The abbreviation P for pancreatic or prostate, ex:
PCa PCa = pancreatic cancer; prostate cancer
The abbreviation H for hand, heart, or hip, ex:
HTx = hand transplantation; hip transplantation; heart transplantation
The abbreviation R for respiratory or renal, ex:
RF = respiratory failure; renal failure
Examples of abbreviations that have contradictory or ambiguous meanings Top ↑
Health practitioners, authors, and editors must do due diligence in creating an abbreviation or they may cause situations similar to the ones shown below. Doing a search for the proposed abbreviation on this website, would be a good beginning. Another possibility is not to abbreviate the phrase or word.
If you have additional examples, please contact us.
| Examples of abbreviations that have contradictory or ambiguous meanings | |
|---|---|
| ABP | ambulatory blood pressure arterial blood pressure |
| ACU | acute receiving unit ambulatory care unit |
| ADVT | acute deep venous thrombosis asymptomatic deep venous thrombosis |
| AHDs | antiherpetic drugs antihypertensive drugs |
| AHRF | acute hypoxemia respiratory failure acute hypercapnic respiratory failure |
| AMI | amifostine amitriptyline acute mesenteric ischemia acute myocardial infarction |
| APC | advanced pancreatic cancer; advanced prostate cancer |
| AQoL | Acne Quality of Life Assessment of Quality of Life Asthma-related Quality of Life Australian Quality of Life |
| ASHL | acute sensorineural hearing loss asymmetric sensorineural hearing loss autoimmune sensorineural hearing loss left ear hearing loss |
| ATR | atropine atracurium |
| AZT | zidovudine azathioprine |
| BAQ | Brief Aggression Questionnaire Body Awareness Questionnaire Buss-Perry Aggression Questionnaire |
| BCa | bladder cancer breast cancer bone cancer |
| BDG | benign gastric disease(s) benign gynecological disease |
| BIQ | Behavioral Inhibition Questionnaire Behavioral Intentions Questionnaire Body Image Questionnaire |
| BLC | blood lactate concentration blood lead concentration |
| BMRI | (whole) body magnetic resonance imaging brain magnetic resonance imaging breast magnetic resonance imaging |
| BO | bowel open bowel obstruction |
| BPM | beats per minute breaths per minute |
| BR | bright red brown |
| BSS | Bernard-Soupier syndrome Brown-Sequard syndrome Brooke-Spieler syndrome Berardinelli-Seip syndrome blood stasis syndrome |
| BV | betamethasone valerate brentuximab vedotin bevacizumab |
| BVC | bevacizumab bupivacaine |
| CABF | carotid artery blood flow celiac artery blood flow cerebral arterial blood flow coronary artery blood flow |
| CAS | carotid artery stenosis cerebral arteriosclerosis coronary artery stenosis |
| CBS | Charles Bonnet syndrome chronic brain syndrome corticobasal syndrome |
| CCF | carotid cavernous Fistula cholecystocutaneous Fistula |
| CESI | cervical epidural steroid injection caudal epidural steroid injection |
| CF | cystic fibrosis Caucasian female calcium leucovorin (citrovorum factor) complement fixation cancer-free cardiac failure coronary flow contractile force Christmas factor count fingers cisplatin fluorouracil |
| CFIs | chemotherapy-free intervals contraceptive-free intervals |
| CIA | chemotherapy-induced amenorrhea chemotherapy-induced anemia chemotherapy-induced alopecia |
| CINP | chemotherapy-induced neuropathic pain chronic idiopathic neck pain |
| CLD | chronic liver disease chronic lung disease cholestatic liver disease chronic lyme disease |
| CLOF | clofarabine clofazimine |
| CPM | cyclophosphamide chlorpheniramine maleate |
| CPS | Chest Pain Syndrome Chinese Paralytic Syndrome Chronic Pain Syndrome |
| CPZ | chlorpromazine Compazine |
| CRS | Chinese restaurant syndrome congenital rubella syndrome cytokine-release syndrome |
| CT surgery | cardiothoracic surgery carpal tunnel surgery |
| CZP | carbamazepine certolizumab pegol clonazepam |
| DAEs | delayed adverse events dermatologic adverse events (dAEs) discontinuation due to adverse events donor adverse events drug adverse effects |
| DCd | deceased discharged discontinued |
| DCLD | decompensated chronic liver disease diffuse cystic lung disease |
| DOG | delay of gratification delusions of grandeur |
| DDS | Denys-Drash Syndrome dialysis disequilibrium syndrome dopamine dysregulation syndrome |
| DDW | deuterium-depleted water distilled-deionized water double-distilled water |
| disc'd | discharged discontinued discussed |
| DNR | daunorubicin did not respond do not report do not resuscitate |
| DOG | delay of gratification delusions of grandeur |
| DS | Down Syndrome Dravet Syndrome |
| DW | dextrose in water distilled water deionized water |
| DXM | dexamethasone dextromethorphan dexmedetomidine |
| ED | eating disorder(s) elbow disarticulation emotional disorder erectile disfunction |
| EIH | environmentally-induced hyperthermia exercise-induced hypertension exercise-induced hyperthermia exercise-induced hypoxemia |
| EOP | early-onset Parkinsonism early-onset pneumonia early-onset preeclampsia early-onset psychosis |
| ERT | enzyme replacement therapy estrogen replacement therapy |
| ESLD | end-stage liver disease end-stage lung disease |
| FEC | fluorouracil, epirubicin, and cyclophosphamide fluorouracil, etoposide, and cisplatin |
| FSW | female sex worker field service worker |
| GCT | germ cell tumor giant cell tumor granulosa cell tumor |
| GD | Graves disease Gaucher disease |
| GEM | gemfibrozil; gemicitabine |
| HAO | hand osteoarthritis hip osteoarthritis |
| HCC | Hepatocellular carcinoma Hurthle cell carcinoma |
| HD | Hansen disease Hirschsprung disease Hodgkin disease Huntington disease |
| HH | hypohomocysteinemia hyperhomocysteinemia |
| HO | hand orthosis hip orthosis |
| HPW | healthy pregnant women hypertensive pregnant women |
| HTx | hand transplantation heart transplantation |
| IA | intra-amniotic intra-arterial intra-articular |
| IAD | incontinent associated dermatitis intractable atopic dermatitis |
| IAI | Intra-abdominal infection Intra-abdominal injury |
| IBC | invasive bladder cancer invasive breast cancer |
| IBV | infectious bronchitis virus influenza B virus |
| ICA | internal carotid artery intracranial abscess intracranial aneurysm |
| I & D | incision and drainage irrigation and debridement |
| IHHD | in-hospital hemodialysis intensive home hemodialysis |
| IIH | Iodine-induced hyperthyroidism idiopathic infantile hypercalcemia idiopathic intracranial hypertension |
| IPCU | inpatient palliative care unit intensive pediatric care unit intensive psychiatric care unit |
| IRDM | insulin-required diabetes mellitus insulin resistant diabetes mellitus |
| IRF | impaired renal function Improvement in renal function |
| IT | intrathecal intratracheal intratumoral |
| JCV | John Cunningham virus Jamestown Canyon virus |
| KET | ketamine ketoconazole |
| KS | Kawasaki Syndromee Klinefelter Syndrome Korsakoff Syndrome |
| LAM | laminectomy laparoscopic-assisted myomectomy laser-assisted myringotomy |
| LAPC | locally-advanced pancreatic cancer locally-advanced prostatic cancer |
| LAS | lactic acidosis syndrome laxative abuse syndrome lymphadenopathy syndrome |
| LB | left breast left buttock low back lower body |
| LEN | lenacapavir lenalidomide |
| LF | left foot little finger long finger |
| LFD | lactose-free diet low fat diet low fiber diet |
| LGS | leaky gut syndrome Lennox-Gastaut syndrome |
| LHSH | long-handled shoe horn long-handled shower head |
| LKT | laparoscopic kidney transplantation liver-kidney transplantation |
| LL | left leg left lung lower lid lower limb lower lip |
| LNE | lymph node enlargement lymph node excision |
| LNU | learned nonuse (splint) lower and upper (heard as L N U) |
| LOPD | late-onset Parkinson disease late-onset Pompe disease |
| LT | liver transplantation Lung transplantation |
| LTF | longterm follow-up lost to follow-up |
| LTFU | long-term to follow-up loss to follow-up |
| Ltx | liver transplant lung transplant |
| LVO | left ventricular opacification left ventricular output left ventricular overactivity |
| MBC | male breast cancer metastatic breast cancer |
| MDD | major depression disorder manic depression disorder |
| MFS | Marfan syndrome Miller-Fisher syndrome monofixation syndrome |
| MIGS | micro-invasive glaucoma surgery minimally invasive glaucoma surgery minimally invasive gynecological surgery |
| MLS | Maroteaux-Lamy syndrome McLeod neuroacanthocytosis syndrome |
| MON | Monday month |
| MP | melphalan; prednisone mitoxantrone; prednisone |
| MPM | malignant peritoneal mesothelioma malignant pleural mesothelioma |
| MS | morphine sulfate multiple sclerosis mitral stenosis musculoskeletal medical student minimal support muscle strength mental status milk shake mitral sound morning stiffness |
| MTD | maximum tolerated dose minimum toxic dose |
| MTZ | mirtazapine mitoxantrone |
| MUD | marijuana use disorder methamphetamine use disorder |
| MV | mechanical ventilation manual ventilation |
| MWS | Mallory-Weiss syndrome Mickety-Wilson syndrome Muckle-Wells syndrome |
| NABS | no active bowel sounds normoactive bowel sounds |
| NAF | Native-American female Negro-American female normal adult female |
| NBM | no bowel movement normal bowel movement nothing by mouth |
| NCS | nevus comedonicus syndrome numb chin syndrome Nutcracker syndrome |
| NE | no effect no enlargement not evaluated |
| NITRO | nitroglycerin sodium nitroprusside |
| NOAC | Non-vitamin k antagonist Oral AntiCoagulant(s); also defined as Novel or New No Oral AntiCoagulant(s) or NO AntiCoagulant(s) |
| NRBCs (nRBCs) | native red blood cells noninfected red blood cells nonparasitized red blood cells normal red blood cells nucleated red blood cells |
| NSAE | neurosensory adverse events nonserious adverse events |
| NVD | neck vein distention no venous distention |
| OHS | obesity hypoventilation syndrome ocular histoplasmosis syndrome ocular hypoperfusion syndrome |
| OLB | open-liver biopsy open-lung biopsy |
| OPC | operable pancreatic carcinoma oropharynx cancer oropharyngeal candidiasis |
| PAA | popliteal artery aneurysm pulmonary artery aneurysm |
| PAVF | pial arteriovenous fistula pulmonary arteriovenous fistula |
| PBL | primary breast lymphoma primary brain lymphoma |
| PBZ | phenylbutazone pyribenzamine phenoxybezamine |
| PCS | pelvic congestion syndrome post cholecystectomy syndrome postconcussion syndrome |
| PCU | palliative care unit primary care unit progressive care unit protective care unit |
| PD | Paget disease panic disorder Parkinson disease personality disorder Peyronie disease |
| PHTN | portal hypertension prehypertension postpartum hypertension primary hypertension pediatric hypertension pulmonary hypertension |
| Pit | Pitocin Pitressin |
| PLB | percutaneous liver biopsy percutaneous lung biopsy |
| PLNs | pancreatic lymph nodes parametrial lymph nodes pelvic lymph nodes popliteal lymph nodes positive lymph nodes pyloric lymph nodes |
| PMD | pretomanid Primidone |
| PMS | Phelan-McDermid Syndrome postmenopausal syndrome postconcussion syndrome |
| PNUS | perineal ultrasound peripheral nerve ultrasound prenatal ultrasound |
| PNS | paraneoplastic syndrome(s) paraneoplastic neurological syndrome(s) primary nephrotic syndrome pudendal nerve entrapment syndrome |
| POMI | perioperative myocardial infarction (from the time of admission to discharge) postoperative myocardial infarction (occurring after surgery) |
| PORT | postoperative radiotherapy postoperative respiratory therapy prostate-only radiotherapy |
| PSAH | perimesencephalic subarachnoid hemorrhage primary subarachnoid hemorrhage pseudo subarachnoid hemorrhage |
| pTBI | pediatric traumatic brain injury penetrating traumatic brain injury |
| PTLD | post-transplant lymphoproliferative disorder post-treatment Lyme disease post-tuberculosis lung disease |
| PUO | pruritus of unknown origin pyrexia of unknown origin |
| PVO | peripheral vascular occlusion portal vein occlusion pulmonary venous occlusion |
| PWD | person(s) with a disability people with dementia patients with diabetes |
| PWH | patients with hemophilia patients with HIV |
| QM | every monday month morning |
| RALP | robotic-assisted laparoscopic prostatectomy robotic-assisted laparoscopic pyeloplasty |
| RB | right breast right buttock |
| RFTs | renal function test respiratory function tests |
| RM | radical mastectomy reduction mammoplasty |
| RPBC | rapidly proliferating breast cancer receptor-positive breast cancer |
| RS | Reiter syndrome Rett syndrome Reye syndrome Richter syndrome Rumination Syndrome Raynaud disease (syndrome) |
| RT | radiation therapy recreational therapy respiratory therapy |
| RTI | reproductive tract infection respiratory tract infection |
| RTS | radial tunnel syndrome Rothmund-Thomson syndrome Rubinstein-Taybi syndrome |
| RWW | raw wastewater reclaimed wastewater |
| S & S | swish and spit swish and swallow |
| SA | suicide alert suicide attempt |
| SAD | social anxiety disorder seasonal affective disorder |
| SALF | severe acute liver failure subacute liver failure |
| SCAD | spontaneous cervical artery dissection spontaneous coronary artery dissection stable coronary artery disease |
| SCCL | solitary cerebral cysticercal lesion squamous cell cancer-like squamous cell carcinoma of the larynx squamous cell carcinoma of the lung squamous cell carcinoma of the lip |
| SCCP | squamous cell carcinoma of the penis small cell carcinoma of the prostate |
| SDBP | seated, standing, or supine diastolic blood pressure |
| SDRT | single-dose radiotherapy seasonal affective disorder |
| SDS | Schwann-Diamond Syndrome somatropin deficiency syndrome sudden death syndrome |
| SGAs | second generation antihistamines second generation antipsychotics |
| SICH | spontaneous intracerebral hemorrhage supratentorial intracerebral hematoma symptomatic intracranial hemorrhage |
| SJS | Schwartz-Jampel syndrome Stevens-Johnson syndrome Sawyer-James syndrome |
| SMQ | science motivation questionnaire Selective Mutism Questionnaire Sexual Modes Questionnaire Short-Memory Questionnaire Social Motivation Questionnaire Southampton Mindfulness Questionnaire Sports Motivation Questionnaire Standardized MedDRA Queries States of Mind Questionnaire |
| SMS | scalded mouth syndrome Smith-Magenis syndrome stiff-man syndrome |
| SOBT | salivary occult blood test stool occult blood test |
| SPT | sitting pivot transfer squat pivot transfer standing pivot transfer |
| SRDs | spine-related diseases syndromic retinal disease systemic rheumatic diseases smoking-related diseases stress-related diseases substance-related diseases |
| SS | sacral slope sacrosciatic saline soak saline solution saliva sample self-selected serotonin syndrome serum sickness |
| SSE | saline solution enema soapsuds enema |
| SSS | scalded skin syndrome sick sinus syndrome subclavian steal syndrome |
| ST | Schirmer Test skin test Spurling Test stress test |
| STF | special tube feeding standard tube feeding |
| TAC | tetracaine, Adrenalin, and cocaine solution triamcinolone cream |
| TAMV | time average maximum velocity (blood flow) time-averaged mean velocity (blood flow) |
| TBA | thyroid biochemical abnormalities to be absorbed to be added to be administered to be admitted to be announced to be arranged to be assessed total body (surface) area traditional birth attendant |
| 3TC T&C |
lamivudine (Epivir) Tylenol with 30 mg of Codeine |
| T/E | testosterone to epitestosterone (ratio) testosterone to estrogen (ratio) trunk-to-extremity skinfold thickness (index) |
| TICU | thoracic intensive care unit transplant intensive care unit trauma intensive care unit |
| TMZ | temazepam temozolomide |
| TRZ | thioridazine trastuzumab trazodone triazolam |
| TS | Tay-Sachs (disease) Tourette syndrome Turner syndrome |
| TSCC | thymic squamous cell carcinoma tongue squamous cell carcinoma tonsillar squamous cell carcinoma |
| tubal | tubal ligation tubal pregnancy |
| Tx | therapist therapy traction transcription transfer transfuse transplant transplantation treatment |
| VAC | etoposide (VePesid), cytarabine (ara-C, and carboplatin, vincristine, dactinomycin vincristine, doxorubicin) |
| VAD | vincristine, doxorubicin, (Adriamycin) and dexamethasone vincristine, doxorubicin (Adriamycin) and dactinomycin |
| VAP | vincristine, Adriamycin, and prednisone vincristine, Adriamycin, and procarbazine vincristine, actinomycin D, and Platinol AQ vincristine, asparaginase, and prednisone |
| VDI | vitamin D insufficiency vitamin D intoxication |
| WBRT | whole-brain radiotherapy whole-breast radiotherapy |
| WC | warm compresses wet compresses |
| WS | Waardenburg Syndrome Werner Syndrome West Syndrome Williams Syndrome Withering syndrome |
| WSS | White Spot Syndrome Wiedemann-Steiner Syndrome |
| YOD | year of death year of diagnosis |
Examples of Abbreviations That have been Misread or Misinterpreted that resulted in error Top ↑
We would appreciate receiving other examples of abbreviations that have been misinterpreted causing error or delays so that this section can be expanded - contact us.
(1) "HCT250" was intended to mean hydrocortisone 250 mg but was interpreted as hydrochlorothiazide 50 mg(HCTZ50 mg).
(2) Flucytosine was improperly abbreviated as 5 FU, causing it to be read as fluorouracil. Flucytosine is abbreviated 5 FC and fluorouracil is 5 FU.
(3) Floxuridine was improperly abbreviated as 5 FU, causing it to be read as fluorouracil. Floxuridine is abbreviated FUDR and fluorouracil is 5 FU.
(4) MTX was thought to be mechlorethamine. MTX is methotrexate and mechlorethamine is abbreviated HN2.
(5) The abbreviation "U" for unit is the most dangerous one in the book, having caused numerous tenfold insulin and heparin overdoses. The word unit should never be abbreviated. The handwritten U for unit has been mistaken for a zero, causing tenfold errors. The handwritten U for unit has also been read as the number four, six, and as "cc".
(6) OD, meant to signify once daily, has caused Lugol's solution to be given in the right eye.
(7) OJ meant to signify orange juice, looked like OS and caused saturated solution of potassium iodide to be given in the left eye.
(8) IVP, meant to signify intravenous push (Lasix 20 mg IVP), caused a patient to be given an intravenous pyelogram which is the usual meaning of the abbreviation.
(9) Na Warfarin (sodium warfarin) was read as "No Warfarin."
(10) The abbreviation "s" for "without" has been thought to mean "with" (c).
(11) The order for PT, intended to signify a laboratory test order for prothrombin time, resulted in the ordering of a physical therapy consultation.
(12) The abbreviation "TAB," meant to signify Triple Antibiotic (a coined name for a hospital sterile topical antibiotic mixture), caused patients to have their wounds irrigated with a diet soda. At another facility, with the same set of circumstances, they did not have TAB, so they used Diet Shasta
(13) A slash mark (/) has been mistaken for a one, causing a patient to receive a 100 unit overdose of NPH insulin when the slash was used to separate an order for two insulin doses:
6 units regular insulin/20 units NPH insulin.
(14) Vidarabine, an antiviral agent, was ordered as ara-A; however, ara-C, which is cytarabine, an antineoplastic agent, was given.
(15) On several occasions, pediatric strength diptheriatetanus toxoids (DT) have been confused with adult strength tetanus-diphtheria toxoids (Td).
(16) DTP is commonly understood to refer to diphtheria-tetanus-pertussis vaccine, but in some hospitals it is also used as shorthand for a sedative cocktail of Demerol, Thorazine, and Phenergan. Several cases have occurred where a child was vaccinated rather than given a sedative mixture.
(17) What does the abbreviation MR mean? Some will guess measles-rubella vaccine (M-R Vax II, Merck), while others will assume mumps-rubella vaccine (Blavax II, Merck).
(18) The abbreviation TIW (three times a week) was thought to mean Tuesday and Wednesday when the I was read as a slash mark. Due to confirmation bias (you see what you know), this uncommon abbreviation is seen as the more commonly used T1D (three times a day).
(19) PCA, meant to be procainamide, was interpreted as patient-controlled analgesia.
(20) PGE1 (alprostadil, Caverject) was read as P6 E1 (Alcon's ophthalmic 6% pilocarpine and 1% epinephrine solution).
(21) A nurse transcribed an oral order for the antibiotic aztreonam as AZT, which was subsequently thought to be the antiviral drug zidovudine.
(22) An order for TAC 0.1%, intended to mean triamcinolone cream, was interpreted as tetracaine, Adrenalin, and cocaine solution.
(23) An order for SPA (salt poor albumin) was overlooked because it was not recognized as a drug order.
(24) Therapy was delayed and considerable professional time was wasted when an order for
"Bactrim SS q 12 h on S/S" had to be clarified (Bactrim Single Strength every 12 hours on Saturday and Sunday).
(25) A physician wrote an order stating "may take own supply of EPO". The physician meant evening primrose oil, not Epogen (epoetin alfa).
(26) 4-MP was recommended to treat ethylene glycol poisoning. The medical resident mistakenly interpreted this as 6-MP (6-mercaptopurine). 4-MP is fomepizole (4-methylpyrazole) and 6-MP is mercaptopurine (6-mercaptopurine).
(27) An order for lomustine stated it was to be given at "hs". This was misinterpreted as to mean every night. After continuous administration, toxicity resulted in the patient's death. The drug is normally given once every 6 weeks. State complete orders such as "HS_ 1 dose today," "HS nightly," or "HS nightly PRN for sleep."
(28) The directions for an order for Cortisporin Otic Solution indicated "Three drops in R ear T1D." The patient was given the drops in the rear rather than the right ear.
(29) There have been mix-ups between IL-2 and IL-11 when IL-2 is expressed as IL-II (Roman numeral 2). The II has been read as "IL eleven," and vice versa. IL-2 (interleukin 2) is aldesleukin (Proleukin) and IL-11 is oprelvekin (Neumega).
(30) A drug was ordered "Q 10 h." It was read as QID (four times daily). Drugs should not be ordered at unusual hourly intervals such as every 10, 18, 36 hours, as this has resulted in a host of errors. Standard times are every 2, 3, 4, 6, 8, or 12 hours; once, twice, three, or four times daily; every day, or Monday, Wednesday, and Friday and once weekly.
(31) 6 IU was read as 61 units instead of the intended 6 international units.
(32) A dose of phenytoin was modified and expressed as mg/Kg/d. The d was read as "dose" rather than the intended "day" resulting in 3 extra doses being given.
(33) An order appeared as, "If no BM in PM give MOM in AM p.r.n."
(34) Sometimes ambiguous abbreviations cause financial losses to health providers. for example, an insurance provider may pay less for an office visit for mental retardation than it does for mitral regurgitation. This can happen if the coder is faced with the abbreviation MR.
(35) The abbreviation for "q PM" has been read as 9 PM (a one time dose at 9 PM) rather than every night.
(36) An order was written in a hospital, "Cortisporin 3 drops, AS bid." There was a question about the meaning of AS, but since the patient was scheduled for a colonoscopy it was decided that the meaning was anal sphincter, so the drug was administered rectally rather than in the left ear as intended. When the patient was asked to roll over for their medicine, I suppose they could have protested that there was nothing wrong with their rectum, but then again, maybe this was part of a complex preparation for their colonoscopy!
(37) A liver transplant patient on readmission had an order handwritten, "MMF 1000 mg PO BID (mycophenolate mofetil)." Mycophenolate mofetil is the immunosuppressive agent CellCept which has been abbreviated MMF. The order was misread as 1000 mg twice 1 daily MWF (Monday, Wednesday, and Friday). Several doses of this critical drug were omitted before the error was discovered.
(38) A prescription was written for PTU. PTU normally means propylthiouracil, however Purinethol was dispensed in error causing a fatality. Purinethol is never abbreviated PTU. The error probably occurred because both propylthiouracil and Purinethol are available in 50 mg tablets and sit side-by-side on the pharmacy shelf. The prescriber contributed to the error by using nonstandard terminology, an abbreviation.
(39) A nurse mistakenly administered Chloral Hydrate intravenously. This syrup is intended for oral administration only. This was done because the label contained the legend C IV. This was interpreted as intravenous when in fact, C IV stands for a class 4 controlled substance. All controlled substances are indicated as Roman numerals, I, II, III, IV, V. Even though 99.9% of nurses know that drugs in screw-capped bottles, labeled "syrup" are not intended for intravenous administration, it would pay to change C IV to C4 on drug labels.
(40) After performing spinal surgery a surgeon kept his ICU patients NPO (nothing by mouth), until they had flatus and good bowel sounds. His order was: "Strict NPO. Check BS Q2H." The patient had "blood sugar" laboratory tests drawn Q2H!
(41) An infant died when she received 5 mg of morphine instead of the prescribed ".5 mg" dose when the naked decimal point was not seen with handwritten orders. This can easily occur if the decimal point happens to fall on a line, or falls on part of a letter from the line above, or when working from poor copies of an original order. Always place a zero in front of a naked decimal (0.5 mg, not .5 mg).
(42) An order was written for Colchicine 1.0 mg IV now. The decimal point was not seen and 10 mg was administered. The patient died. This can easily occur with a handwritten order if the decimal point happens to fall on a line, or falls on part of a letter from the line above, or when working from poor copies of the original order. Use 1 mg, not 1.0 mg. A trailing zero can correctly be used where precision is being expressed, such as in reporting a laboratory value, but never in expressing a drug dose or strength.
(43) The pharmacy received an order for a diltiazem drip. No rate of administration was listed, so the pharmacist entered "125 mg UD" in computer rate field. UD is an old-time Latin abbreviation for as directed (ut dictum). The nurse did not know the classical meaning of UD and interpreted as meaning unit dose. The nurse then proceeded to give the diltiazem at 125 mg/hr and ran the entire dose over one hour (the rate should have been 5 mg/hr). The nurse then asked for another diltiazem drip and also ran that one over 1 hour. The patient expired. One of the many factors in causing this error was the use of an ancient abbreviation which should no longer be used.
(44) An order was written for lidocaine 1% S EPINEPHrine. It was misinterpret as lidocaine 1% with EPINEPHrine. S is a Latin-derived abbreviation for "without" which is rarely used. "Lidocaine 1%" is a safer way to express this order.
(45) DNR usually means, "do not resuscitate" but also has been used for the drug, daunorubicin, "do not report", and, "did not respond". We are not as yet familiar with any mix-ups, but anything can happen!
(46) An order was written, "....Patient is taking Coumadin and was placed on amiodarone. There is an interaction. Instead of adjusting coumadin dose, consider NoAC." This was interpreted to mean "no anticoagulant" rather than its intended meaning, "new [noval] oral anticoagulant[s] (rivaroxaban [Xarelto], dabigatran [Pradaxa] and apixaban [Eliquis]").
(47) An order was written," PT TO SEE PT WHEN PT WNL", which was translated as "Patient to see physical therapy when prothrombin is within normal limits" This did not cause an error, but did slow things down!
(48) In an emergency department, at physician asked the nurse to get the drug TXA. The nurse thought he said TNK. She brought the physician TNKase. The potential mistake was discovered and an error did not occurred. TXA is tranexmaic acid injection (Cykiokapron) and TNK is tenecteplase injection (TNKase).
(49) ANIN could be identified. It turned out to be a typo for two words, an in.
(50) ONJ could be identified. It turned out to be a typo for the word, on.
(51) An order for tPA (alteplase [Activase]) was thought to be TPN (total parental nutrition) causing a delay in initiating critical therapy.
(52) Due to a typo or transcription error, Dicem could not be identified. It should have been, Dycem, a nonslip material used by occupational therapists.
References
1. Davis NM, Cohen MR. Medication Errors; Causes and Prevention. Warminster, PA; Neil M Davis Associates; 1983.
2. Cohen MR. Medication error reports. Hosp Pharm (appears monthly from 1975 to the present).
3. Cohen MR, Medication errors. Nursing 2018 (appears monthly, starting in Nursing 77, to the present).
4. Davis NM, Med Errors. Am J Nursing (appears monthly from 1995 to 1995).
5. Cohen MR, Medication Errors. American Pharmaceutical Assoc. Wash. DC, 2007.
Become a Subscriber
To take full advantage of MedAbbrev.com's extensive database of abbreviations, acronyms, and drug names, become a subscriber today.
