Recent study findings reinforce the value of The Joint Commission's "Do Not Use" list of taboo abbreviations. Researchers found that nearly 5% (about 30,000) of all errors reported to the United States Pharmacopeia Medmarx program between 2004 and 2006 involved abbreviations. The most common abbreviation resulting in drug errors, accounting for 43.1% of all such errors, was QD (once daily). This abbreviation, already on the Do Not Use list, is often mistaken for similar abbreviations, such as QOD (every other day). Other common abbreviations that resulted in medication errors were:
* U for units, which can be mistaken for 0 (zero), the number four, or cc
* cc for mL, which may be mistaken for U (units) when poorly written
* MSO4 (magnesium sulfate) or MS (morphine sulfate); these abbreviations are easily confused.
Eighty-one percent of errors occurred during prescribing. Abbreviation errors originated most frequently with medical staff, compared with nursing, pharmacy, or other health care providers.
The study findings suggest that some additions to The Joint Commission's Do Not Use list, first introduced in 2004, may be in order. Researchers urge facilities to add these to their own lists: drug name abbreviations (such as PCN, DCN, TCN), stem abbreviations (such as amps, nitro, succs), [mu] (use mcg or write out micrograms instead), cc (use mL or write out milliliters instead), or dose scheduling abbreviations, such as BID, TID, or QID.
Brunetti L, et al., The impact of abbreviations on patient safety, The Joint Commission Journal on Quality and Patient Safety, September 2007.