Practitioners' Reporting News

Abbreviation Errors

Issued June 30, 2005

The following summaries are a sample of reports submitted to USP's Medication Errors Reporting Program involving abbreviations.

  1. MONOJECT PreFill™ Heparin Lock Flush-Dangerous "U"
  2. Mu Persists with Hectorol®
  3. Symbol Overlooked
  4. "TAC," What Does It Stand For?
  5. Confusing Packaging—"cc" and "mL"
  6. "bed" Translated as "bid"
  7. Does "A" Stand for Albuterol or Atrovent®?
  8. Expiration Debate: "JN" = January or June?

MONOJECT PreFill™ Heparin Lock Flush-Dangerous "U"


Potential error: A pharmacist was evaluating the switch to MONOJECT PreFill heparin lock flush syringes; specifically the 10unit/mL (5mL) and 100unit/mL (10mL). To the pharmacist's surprise, the manufacturer uses the abbreviation "U" for units on the syringe. According to the reporting pharmacist, the syringes read "100U/mL Heparin Lock Flush" and "10U/mL Heparin Lock Flush", although the outer wrapping spells out the word units. The pharmacist expressed concern that the facility was having difficulty trying to move away from dangerous abbreviations for obvious safety reasons, and was very surprised to see this abbreviation so prominently displayed on the product's label.
Reporting pharmacist's recommendation: To avoid any increased risk to patients, the facility will discontinue use of this product and consider other safer alternatives.



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Mu Persists with Hectorol®


To view a prior report published on the injectable form of this product, click here.

Potential error: The Hectorol tablet label displays the Greek letter mu (i.e., μg), rather than "mcg" to designate micrograms.


Front
Side
Photo of Hectorol label*



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A technician and pharmacist discovered the labeling while repackaging the tablets into unit-dose. Reporting pharmacist's recommendation: The facility's labeling policy does not permit the use of μg as a designation for micrograms.
Reporting pharmacist's recommendation: The facility's labeling policy does not permit the use of μg as a designation for micrograms.

Symbol Overlooked


Error description: A pharmacy technician delivered Xigris® to the patient care area. The nurse questioned why Xigris was dispensed when she wrote an order to discontinue the medication. The pharmacist renewed the medication because the order below was interpreted incorrectly.


Photo of order to discontinue Xigris*

The symbol Ø was meant to indicate that Xigris was NOT to be restarted.



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"TAC," What Does It Stand For?


Error description: A dermatologist wrote an order for "TAC 0.1% apply TID to affected areas." The patient's provider interpreted it as tetracaine/adrenaline/cocaine and submitted a non-formulary request for the medication. Fortunately, the pharmacist intervened and clarified the order with the prescribing dermatologist as triamcinolone cream 0.1%. A few months later, a nursing home patient presented an order for "TAC 0.1% to affected areas TID" from the same dermatologist. The physician interpreted the prescription as tacrolimus 0.1% and submitted a non-formulary request for the medication. The pharmacist noticed the similarity to the previous prescription and the order was clarified as triamcinolone 0.1%.
Reporting pharmacist's recommendation: The pharmacist asked the physician to write out triamcinolone. The physician stated that he did not realize the abbreviation was a problem, but agreed to stop using "TAC." The pharmacist notified all physicians, clinical pharmacists, physician assistants, and nurse practitioners at the facility as well as the outpatient clinics.



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Confusing Packaging—"cc" and "mL"


Potential for Error: The dropper for GlaxoSmithKline's Lanoxin® Elixir Pediatric solution utilizes "cc" for dosing, while the packaging states "mL" for milliliters. "cc" is a known abbreviation that should be avoided. It is challenging for practitioners to remove banned abbreviations from common practice when manufacturers continue to use them in labeling products. It is also confusing for a patient or caregiver who may be unaware that 1 cc = 1 mL.


Photo of confusing labeling*



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"bed" Translated as "bid"


Error description: A pharmacy received the following order for Lantus® insulin.


Photo of Lantus order*

The physician was apparently trying to avoid the HS or BT abbreviations for bedtime that have been implicated in reported medication errors. However, the pharmacist interpreted the prescription as "Lantus 5 units subcutaneous bid." The pharmacist knew that Lantus is typically given once daily and usually at night, so the pharmacist questioned the BID order. In fact, the orders intent was at bedtime.
Reporting pharmacist's recommendation: It was suggested that in the future the physician designate the time in which the medication should be administered.



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Does "A" Stand for Albuterol or Atrovent®?


Error description: Nephron Pharmaceutical Corporation identifies their two nebulizer solutions with an "A" for albuterol or "I" for ipratropium on the tip of the plastic ampul. However, nurses continuously confused the "A" for Atrovent, which is the common brand name for ipratropium instead of albuterol.
Reporting pharmacist's recommendation: Packaging for these products should be changed to eliminate confusion.



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Expiration Debate: "JN" = January or June?


Potential error: Axcan Scandipharm's Canasa® (Mesalamine) suppositories list "JN" followed by a 2-digit calendar year as an expiration date. It is unclear if "JN" stands for January or June, however, it was assumed that the medication expired at the end of January since that is the earlier of the two months in question. This is very confusing.

Note: Expiration Date and Beyond-Use Date labeling requirements can be found in USP 28-NF 23 under the General Notices and Requirements, pg. 11:

"The label of an official drug product or nutritional or dietary supplement product shall bear an expiration date. All articles shall display the expiration date so that it can be read by an ordinary individual under customary conditions of purchase and use. The expiration date shall be prominently displayed in high contrast to the background or sharply embossed, and easily understood (e.g., "EXP 6/89," "Exp. June 89," or "Expires 6/89"). [NOTE—For additional information and guidance, refer to the Nonprescription Drug Manufacturers Association's Voluntary Codes and Guidelines of the OTC Medicines Industry.]"



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Similar medication errors can submitted to the MER Program via a secure online form or by calling 1-800-23-ERROR (1-800-233-7767) to request a reporting form.

*Photos provided courtesy of the reporter or the Institute for Safe Medication Practices.