Institute for Safe Medication Practices

ISMP’s List of Error-Prone Abbreviations, Symbols,

and Dose Designations
he abbreviations, symbols, and dose
T designations found in this table have been
reported to ISMP through the ISMP National
nicating medical information. This includes
internal communica- tions, telephone/verbal
prescriptions, computer-generated
Medication Errors Reporting Program (ISMP labels, labels for drug storage bins, medication
MERP) as administration records, as well as pharmacy
being frequently misinterpreted and involved in and prescriber computer order entry screens.
harmful medication errors. They should
NEVER be used when commu-
Abbreviations Intended Meaning Misinterpretation
Correction
µg Microgram Mistaken as “mg” Use “mcg”
AD, AS, AU Right ear, left ear, each ear Mistaken as OD, OS, OU (right eye, left eye, each eye) Use
“right ear,” “left ear,” or “each ear”
OD, OS, OU Right eye, left eye, each eye Mistaken as AD, AS, AU (right ear, left ear, each ear) Use
“right eye,” “left eye,” or “each eye”
BT Bedtime Mistaken as “BID” (twice daily) Use “bedtime”
cc Cubic centimeters Mistaken as “u” (units) Use “mL”
D/C Discharge or discontinue Premature discontinuation of Use “discharge” and
medications if D/C (intended to mean
“discharge”) has been misinterpreted as “discontinue”
“discontinued” when followed by a list of
discharge medications
IJ Injection Mistaken as “IV” or “intrajugular” Use “injection”
IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or
“NAS”
HS Half-strength Mistaken as Use “half-strength” or
bedtime “bedtime”
hs At bedtime, hours
of sleep Mistaken as half-
strength
IU** International unit Mistaken as IV (intravenous) or 10 (ten) Use “units”
o.d. or OD Once daily Mistaken as “right eye” (OD-oculus Use “daily”
dexter), leading to oral liquid medications
administered in the eye
OJ Orange juice Mistaken as OD or OS (right or left eye); Use "orange juice"
drugs meant to be diluted in orange juice may be
given in the eye
Per os By mouth, orally The “os” can be mistaken as “left eye” (OS-oculus sinister) Use
“PO,” “by mouth,” or “orally”
q.d. or QD** Every day Mistaken as q.i.d., especially if the Use “daily”
period after the “q” or the tail of the “q” is
misunderstood as an “i”
qhs Nightly at bedtime Mistaken as “qhr” or every hour Use “nightly”
qn Nightly or at bedtime Mistaken as “qh” (every hour) Use “nightly” or
“at bedtime”
q.o.d. or QOD** Every other day Mistaken as “q.d.” (daily) or “q.i.d. Use “every other day”
(four times daily) if the “o” is poorly written
q1d Daily Mistaken as q.i.d. (four times daily) Use “daily”
q6PM, etc. Every evening at 6 PM Mistaken as every 6 hours Use “daily at 6
PM” or “6 PM daily”
SC, SQ, sub q
Subcutaneous SC mistaken as SL (sublingual); SQ mistaken as
“5 every;” the “q” in “sub q” has been mistaken Use “subcut” or
as “every” (e.g., a heparin dose ordered “sub q 2 “subcutaneously”
hours before surgery” misunderstood as every 2
hours before surgery)
ss Sliding scale Mistaken as “55” Spell out “sliding scale;”
(insulin) or ½ use “one-half” or
(apothecary) “½
”
 SSRI Sliding scale Mistaken as selective-serotonin Spell out “sliding scale
regular insulin reuptake inhibitor (insulin)”
SSI
Sliding scale Mistaken as Strong Solution of
insulin Iodine (Lugol's)
i/d One daily Mistaken as “tid” Use “1 daily”
TIW or tiw 3 times a week Mistaken as “3 times a day” or “twice in a week” Use “3
times weekly”
U or u** Unit Mistaken as the number 0 or 4, causing a
10-fold overdose or greater (e.g., 4U seen as Use “unit”
“40” or 4u seen as “44”); mistaken as “cc” so
dose given in volume instead of units (e.g., 4u
seen as 4cc) Use “as directed”
UD As directed (“ut Mistaken as unit dose (e.g., diltiazem 125 mg IV
dictum”) infusion “UD” misin- terpreted as meaning to
give the entire infusion as a unit [bolus] dose)
Dose Intended Meaning Misinterpretation Correction
Designations
and Other
Information 1 mg Mistaken as 10 mg if the decimal point is not seen Do not
Trailing zero use trailing zeros for
after decimal doses expressed in
point (e.g., whole numbers
1.0 mg)** 0.5 mg Mistaken as 5 mg if the decimal point is not seen Use zero
“Naked” decimal before a decimal point when
point the dose is less than a whole
(e.g., .5 unit
mg)**
Abbreviations such as The period is unnecessary and could be mistaken Use mg, mL, etc. without
mg. mg as the number 1 if written poorly a terminal period
or mL. with a period
following the
abbreviation mL
Institute for Safe Medication Practices

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose

Dose
Designations
Designations (continued)
and Other Intended Meaning Misinterpretation Correction
Information
Drug name and Inderal 40 Mistaken as Inderal 140 mg Place adequate space
dose run together between the drug name,
(especially mg
Mistaken as Tegretol 1300 mg dose, and unit of measure
problematic for
drug names that Tegretol
end in “l” such as 300 mg
Inderal40 mg;
Tegretol300 mg) The “m” is sometimes mistaken as a zero or
two zeros, risking a Place adequate space between
Numerical dose 10- to 100-fold overdose the dose and unit of measure
and unit of 10 mg
measure run
together (e.g., 100 mL 100000 has been mistaken as 10,000 or Use commas for dosing units at
10mg, 100mL) 1,000,000; 1000000 has been mistaken as or above
100,000 100,000 1,000, or use words such as 100
Large doses units "thousand" or 1 "million" to
without properly improve
placed commas 1,000,000 readability
(e.g., 100000 units; units
1000000
units)
Drug Name Abbreviations Intended Meaning Misinterpretation
Correction
To avoid confusion, do not abbreviate drug names when communicating medical information. Examples of drug name
abbreviations involved in medication errors include:
APAP acetaminophen Not recognized as acetaminophen
Use complete drug name ARA A vidarabine Mistaken as cytarabine (ARA C)
Use complete drug name AZT zidovudine (Retrovir) Mistaken as azathioprine or
aztreonam Use complete drug name CPZ Compazine (prochlorperazine)
Mistaken as chlorpromazine Use complete drug name DPT
Demerol-Phenergan-Thorazine Mistaken as diphtheria-pertussis-tetanus (vaccine) Use
complete drug name
DTO Diluted tincture of opium, or deodorized tincture of
opium (Paregoric)
Mistaken as tincture of opium
Use complete drug name
HCl hydrochloric Mistaken as potassium Use complete drug name
acid or chloride unless expressed as a salt of a
hydrochloride (The “H” is drug
misinterpreted as “K”)
HCT hydrocortisone Mistaken as hydrochlorothiazide
Use complete drug name HCTZ hydrochlorothiazide Mistaken as hydrocortisone (seen as
HCT250 mg) Use complete drug name MgSO4** magnesium sulfate Mistaken
as morphine sulfate Use complete drug name MS, MSO4** morphine
sulfate Mistaken as magnesium sulfate Use complete drug name MTX
methotrexate Mistaken as mitoxantrone Use complete drug name
NoAC novel/new oral anticoagulant No anticoagulant Use
complete drug name
PCA procainamide Mistaken as patient controlled analgesia
Use complete drug name PTU propylthiouracil Mistaken as mercaptopurine
Use complete drug name T3 Tylenol with codeine No. 3 Mistaken as liothyronine
Use complete drug name TAC triamcinolone Mistaken as tetracaine, Adrenalin,
cocaine Use complete drug name
TNK TNKase Mistaken as “TPA” Use complete drug
name
tissue plasminogen Mistaken as TNKase (tenecteplase), or less
TPA or activator, Activase often as another tissue plasminogen Use complete drug names
tPA (alteplase) activator, Retavase (retaplase)
ZnSO4 zinc sulfate Mistaken as morphine sulfate Use complete drug
name
Stemmed Drug Names Intended Meaning Misinterpretation
Correction “Nitro” drip nitroglycerin infusion Mistaken as sodium nitroprusside infusion
Use complete drug name “Norflox” norfloxacin Mistaken as Norflex
Use complete drug name
“IV Vanc” intravenous vancomycin Mistaken as Invanz Use complete
drug name
Symbols Intended Meaning Misinterpretation
Correction
Dram Symbol for dram Use the metric system
mistaken as “3”
Minim
Symbol for minim
mistaken as “mL”
x3d For three days Mistaken as “3 doses” Use “for three days”
> and < More than and less than Mistaken as opposite of intended; Use “more than” or “less than”
mistakenly use incorrect symbol; “< 10”
mistaken as “40”
/ (slash mark) Separates two Mistaken as the number 1 (e.g., “25 units/10 Use “per” rather than a
doses or units” misread as slash mark to separate
indicates “per” “25 units and 110” units) doses
@ At Mistaken as “2” Use “at”
& And Mistaken as “2” Use “and”
+ Plus or and Mistaken as “4” Use “and”
° Hour Mistaken as a zero (e.g., q2° seen as q 20) Use “hr,” “h,” or
“hour”
Ф or ᴓ zero, null sign Mistaken as numerals 4, 6, 8, and 9
Use 0 or zero, or describe intent using
whole words

**These abbreviations are included on The Joint Commission’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 www.jointcommission.org for more information about this Joint Commission requirement.
© ISMP 2015. Permission is granted to reproduce material with proper attribution for internal use within healthcare organizations. Other reproduction is
prohibited
without written permission from ISMP. Report actual and potential medication errors to the ISMP National Medication Errors www.ismp.org
Reporting Program (ISMP MERP) via the
Web at www.ismp.org or by calling 1-800-FAIL-SAF(E).