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MODULE 35: Medication Order Policies, Range Orders & Stop Rules
Section 35.5: Unapproved Abbreviations: The “Never Use” List and Real Examples from The Joint Commission
A masterclass on the language of medication safety, focusing on the high-risk shortcuts that are strictly forbidden in modern healthcare.
SECTION 35.5
Unapproved Abbreviations
When a Single Letter Can Be Lethal: Decoding the “Do Not Use” List.
35.5.1 The “Why”: The Lethal Potential of a Simple Shortcut
In 2004, The Joint Commission (TJC) took a dramatic step to improve patient safety by establishing its National Patient Safety Goals. One of the very first goals was the standardization of a list of dangerous, error-prone medical abbreviations that were to be strictly forbidden in all accredited healthcare organizations. This was not a suggestion; it was a mandate. Why? Because years of root cause analyses of catastrophic and fatal medication errors had revealed a terrifyingly common theme: a simple, handwritten shortcut, intended to save a few seconds, was misinterpreted by another healthcare professional with deadly consequences.
A hastily scribbled “U” for “units” was misread as a zero, leading to a 10-fold insulin overdose. A trailing zero in “5.0 mg” was missed, and the patient received 50 mg of a potent medication. “MS” for morphine sulfate was mistaken for magnesium sulfate, leading to an opioid overdose in a patient needing electrolytes. These were not theoretical risks; they were real events that caused profound patient harm. The creation of the official “Do Not Use” List was a declaration that the convenience of these abbreviations could never justify their inherent risk.
In the modern EHR, this list is often enforced via hard stops. The system is programmed to recognize and block these forbidden abbreviations, forcing the user to type the full, unambiguous term. However, these shortcuts still appear in handwritten notes, on printed forms, and in verbal communication. Your role as a pharmacist is to be the ultimate guardian of this safety standard. You must have the “Do Not Use” list so deeply ingrained in your practice that you can spot a violation instantly. You are not being “pedantic” or “difficult” when you correct a provider for using one of these abbreviations; you are enforcing a critical national safety standard and preventing a potential tragedy. This section will provide a deep, comprehensive dive into this essential “language of safety.”
Retail Pharmacist Analogy: The Look-Alike, Sound-Alike Drugs
As a retail pharmacist, you are a master of managing ambiguity. Your brain is hardwired to watch for look-alike, sound-alike (LASA) drug pairs that can lead to disastrous errors.
When you see a prescription for “hydralazine,” a part of your brain automatically asks, “Could they have meant hydroxyzine?” When you see an order for Seroquel, you pause to ensure it wasn’t meant to be Sinequan. You have developed automatic, subconscious safety checks to differentiate these pairs. Many pharmacies use visual cues like “Tall Man Lettering” (e.g., hydrOXYzine vs. hydrALAZINE) on shelf labels to prevent mix-ups. This is a system-level approach to mitigating risk from ambiguous names.
The “Do Not Use” list is the ultimate form of “Tall Man Lettering” for medical communication.
Dangerous abbreviations are the written equivalent of LASA drugs. A handwritten “U” looks like a “0.” The abbreviation “MS” sounds like it could mean multiple things. The TJC “Do Not Use” list is a formal, mandatory policy that eliminates this ambiguity entirely by forbidding the dangerous shortcut and demanding the full, clear term. Your daily vigilance in differentiating LASA drugs is the exact same mental muscle you will now apply to identifying and eliminating these forbidden abbreviations. It is a core patient safety skill you have been practicing your entire career.
35.5.2 The Official Joint Commission “Do Not Use” List: A Deep Dive
This list is non-negotiable and applies to all medical orders and all medication-related documentation (e.g., progress notes, MARs) that are not pre-programmed into the EHR. You must know every item, the reason it’s forbidden, and the required correction.
U, u
Intended Meaning
Unit
The Danger: The Ten-Fold Overdose
This is arguably the most dangerous abbreviation in medicine. A poorly written “U” can easily be mistaken for a “0” (zero), a “4” (four), or “cc.” The most common error is mistaking “10U” for “100,” leading to a catastrophic 10-fold overdose of medications like insulin or heparin.
Real-World Error Example
A handwritten order for “10U Regular Insulin” was transcribed into the computer by a ward clerk who misread the “U” as a “0.” The order was entered for 100 units. The pharmacist, under pressure, failed to catch the massive dose. The nurse administered 100 units of insulin. The patient suffered severe, irreversible hypoglycemic brain damage.
The Required Correction
Always write out the word “unit.” There are no exceptions. The EHR hard stop for this abbreviation is one of the most important safety features in the system.
IU
Intended Meaning
International Unit
The Danger: IV Overdose
The abbreviation “IU” is easily mistaken for “IV” (intravenous) or the number “10.”
Real-World Error Example
A physician wrote an order for “Vitamin D 10,000 IU PO daily.” The ‘I’ and ‘U’ were written close together. A nurse misread the order as “Vitamin D 10,000 IV daily.” While this specific error might not be fatal, the same mistake with an order for “10 IU” of insulin could be misread as “10 IV,” leading to a rapid and dangerous IV bolus.
The Required Correction
Always write out the words “International Unit.”
Q.D. / Q.O.D.
Intended Meaning
Daily / Every Other Day
The Danger: Confusion and Overdose
The period after the “Q” can be mistaken for an “I,” making “Q.D.” look like “QID” (four times a day). The abbreviation “Q.O.D.” is even more dangerous, as it can be easily misread as “QD” (daily) or “QID” (four times a day), leading to either daily administration of a drug that should be given every other day, or vice-versa.
Real-World Error Example
An order was written for Coumadin “5mg Q.O.D.” The pharmacist transcribed the order and missed the “O,” entering it as “5mg QD.” The patient received daily warfarin for four days before the error was caught, resulting in a critically elevated INR of 9.5 and a severe GI bleed.
The Required Correction
Write out “daily” and “every other day.” The EHR hard stop on these is universal.
X.0 mg / .X mg
Intended Meaning
X mg / 0.X mg
The Danger: The Wandering Decimal
These two errors are two sides of the same coin and are responsible for countless 10-fold dosing errors.
- Trailing Zero (X.0 mg): The decimal point can be missed, causing an order for “5.0 mg” to be read as “50 mg.”
- Lack of Leading Zero (.X mg): The decimal point can be missed, causing an order for “.5 mg” to be read as “5 mg.”
Real-World Error Example
A pediatric order for morphine “.2 mg” was written without a leading zero. A nurse misread the order as “2 mg,” and administered a 10-fold overdose to the infant, leading to respiratory arrest and death.
The Required Correction
NEVER use a trailing zero for whole numbers. ALWAYS use a leading zero for doses less than one. This should be automatic. Write “5 mg,” not “5.0 mg.” Write “0.5 mg,” not “.5 mg.”
MS, MSO4, MgSO4
Intended Meaning
Morphine Sulfate / Magnesium Sulfate
The Danger: The Ultimate LASA Error
These abbreviations are a catastrophic look-alike, sound-alike mix-up waiting to happen. “MS” can mean either drug. The chemical formulas “MSO4” and “MgSO4” look nearly identical when written quickly.
Real-World Error Example
A patient with eclampsia required magnesium sulfate. The order was written as “MgSO4.” It was misread as “MSO4” (morphine sulfate). The patient was given a large bolus of morphine, leading to respiratory arrest of both the mother and the fetus, resulting in an emergency C-section and neonatal resuscitation.
The Required Correction
Always write out the full drug names: “morphine sulfate” and “magnesium sulfate.” There is zero ambiguity and zero room for error.
35.5.3 Expanding the Field of View: The ISMP List of Error-Prone Abbreviations
While the TJC “Do Not Use” list is the mandatory minimum, the Institute for Safe Medication Practices (ISMP) maintains a much more extensive list of abbreviations that are known to cause errors. While these may not always trigger a hard stop in your EHR, they are considered poor practice and should be avoided and corrected whenever you encounter them. As a medication safety expert, it is your responsibility to champion the use of clear, unambiguous language in all forms of medical communication.
A Curated Selection from the ISMP Error-Prone List
| Abbreviation | Intended Meaning | The Danger & Required Correction |
|---|---|---|
| μg | Microgram | Danger: The “μ” symbol can be misread as “m,” leading to a 1000-fold overdose. An order for 10 μg can be mistaken for 10 mg. Correction: Always write out “mcg” or “microgram.” |
| cc | Cubic centimeter | Danger: A sloppy “cc” can look like a “U” (units), especially with numbers (e.g., “10cc” vs “10U”). Correction: Use “mL” for milliliters. This is the modern standard for liquid volume. |
| HS | At bedtime / Half-strength | Danger: This abbreviation has two common but completely different meanings. Does “Humalog 5 units HS” mean at bedtime or half-strength? Correction: Be specific. Write out “at bedtime” or “half-strength.” |
| D/C | Discontinue / Discharge | Danger: A nurse or pharmacist might see “D/C all meds” in a progress note and discontinue everything, when the intent was to prepare the patient for discharge later in the day. Correction: Write out “discontinue” or “discharge.” |
| TIW | Three times a week | Danger: Easily misread as “TID” (three times a day), leading to significant overdosing of medications like methotrexate or epoetin alfa. Correction: Specify the days of the week. Write “three times weekly” or, even better, “on Mondays, Wednesdays, and Fridays.” |
| AD, AS, AU OD, OS, OU |
Right/Left/Both Ears Right/Left/Both Eyes |
Danger: These Latin abbreviations are easily confused. An ear drop can be mistakenly put in an eye, causing significant pain and injury. Correction: Write out the full words: “right ear,” “left eye,” “both ears.” |
| Drug Name Stems/Shortcuts (e.g., “Nitro,” “HCTZ,” “TAC”) |
Nitroglycerin, Hydrochlorothiazide, Tacrolimus | Danger: While often understood in context, these can be ambiguous. “Nitro” could mean nitroglycerin or nitroprusside. “AZT” has historically been confused between zidovudine and azathioprine. Correction: The safest practice is to always use the full, complete drug name. |
