ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations
he abbreviations, symbols, and dose designations found in this table The Joint Commission (TJC) has established a National Patient T have been reported to ISMP through the USP-ISMP Medication
Safety Goal that specifies that certain abbreviations must appear on Error Reporting Program as being frequently misinterpreted and an accredited organization's do-not-use list; we have highlighted these involved in harmful medication errors. They should NEVER be used items with a double asterisk (**). However, we hope that you will when communicating medical information. This includes internal consider others beyond the minimum TJC requirements. By using communications, telephone/verbal prescriptions, computer-generated and promoting safe practices and by educating one another about labels, labels for drug storage bins, medication administration records, hazards, we can better protect our patients.
as well as pharmacy and prescriber computer order entry screens.
Mistaken as OD, OS, OU (right eye, left eye, each eye) Use “right ear,” “left ear,” or “each ear” OD, OS, OU
Mistaken as AD, AS, AU (right ear, left ear, each ear) Use “right eye,” “left eye,” or “each eye” Premature discontinuation of medications if D/C (intended to mean Use “discharge” and “discontinue” “discharge”) has been misinterpreted as “discontinued” when followedby a list of discharge medications Mistaken as “IV” or “intrajugular” Use “half-strength” or “bedtime” o.d. or OD
Mistaken as “right eye” (OD-oculus dexter), leading to oral liquid Mistaken as OD or OS (right or left eye); drugs meant to be diluted in The “os” can be mistaken as “left eye” (OS-oculus sinister) Use “PO,” “by mouth,” or “orally” q.d. or QD**
Mistaken as q.i.d., especially if the period after the “q” or the tail of the “q” is misunderstood as an “i” q.o.d. or QOD**
Mistaken as “q.d.” (daily) or “q.i.d. (four times daily) if the “o” is q6PM, etc.
Use “6 PM nightly” or “6 PM daily” SC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in SC, SQ, sub q
“sub q” has been mistaken as “every” (e.g., a heparin dose ordered“sub q 2 hours before surgery” misunderstood as every 2 hours beforesurgery) Spell out “sliding scale;” use “one-half” or Mistaken as selective-serotonin reuptake inhibitor Mistaken as Strong Solution of Iodine (Lugol's) TIW or tiw
Mistaken as “3 times a day” or “twice in a week” Mistaken as the number 0 or 4, causing a 10-fold overdose or greater (e.g., 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so dosegiven in volume instead of units (e.g., 4u seen as 4cc) Trailing zero after
Mistaken as 10 mg if the decimal point is not seen decimal point
(e.g., 1.0 mg)**
Mistaken as 5 mg if the decimal point is not seen decimal point
(e.g., .5 mg)**
ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (continued)
Drug name and dose run
together (especially
problematic for drug
names that end in “l”
such as Inderal40 mg;
Tegretol300 mg)
Numerical dose and unit
The “m” is sometimes mistaken as a zero or two zeros, risking a Place adequate space between the dose and of measure run together
(e.g., 10mg, 100mL)
The period is unnecessary and could be mistaken as the number Abbreviations such as mg.
Use mg, mL, etc. without a terminal period or mL. with a period
following the abbreviation
Large doses without
100000 has been mistaken as 10,000 or 1,000,000; 1000000 has properly placed commas
1,000, or use words such as 100 "thousand" (e.g., 100000 units;
or 1 "million" to improve readability 1000000 units)
Mistaken as diphtheria-pertussis-tetanus (vaccine) (The “H” is misinterpreted as “K”) Mistaken as hydrocortisone (seen as HCT250 mg) MS, MSO4**
Mistaken as tetracaine, Adrenalin, cocaine “Nitro” drip
Mistaken as sodium nitroprusside infusion “Norflox”
“IV Vanc”
> and <
Mistaken as opposite of intended; mistakenly use incorrect Use “greater than” or “less than” symbol; “< 10” mistaken as “40” / (slash mark)
Mistaken as the number 1 (e.g., “25 units/10 units” misread as Use “per” rather than a slash mark to Mistaken as a zero (e.g., q2° seen as q 20) I **These abbreviations are included on TJC's “minimum list” of dangerous abbreviations, acronyms and symbols that must be included on an organization's “Do Not Use” list, effective January 1, 2004. Visit for more information about this TJC requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potentialmedication errors to the MERP via the web at or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received andrespects reporters’ wishes as to the level of detail included in publications.


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