USP Quality Review

No. 80, Issued July 2004

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In This Issue:

Abbreviations Can Lead to Medication Errors

Why?—Because abbreviations can be misinterpreted or misunderstood, resulting in serious errors. Review of the USP Medication Errors Reporting (MER) Program (1991-2003) and MEDMARX® (1998-2003) databases identified one hundred ninety-six abbreviations reported to have caused or contributed to a medication error. One of the proposed 2005 National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires accredited facilities (e.g., hospitals) to develop and enforce a standardized list of abbreviations, acronyms, and symbols that should not be used within the facility. The lists provided in this Review can serve as a resource for organizations in meeting this JCAHO goal.

List of Abbreviations:

Table 1 - Pontentially Dangerous Drug Name Abbreviations
Table 2 - Potentially Dangerous Abbreviations
Table 3 - Miscellaneous Abbreviations

The abbreviations listed in these three tables should be shared with all healthcare practitioners to increase awareness about potential medication errors by

  • illustrating the problematic abbreviations in support of the national effort to avoid the use of abbreviations in healthcare
  • comparing the drug products used in each facility with the abbreviations, acronyms, and symbols listed in the tables and targeting those products that can be misinterpreted when abbreviated
  • educating staff on the various misinterpretations that have led to medication errors
  • continually reviewing abbreviations in order to eliminate their use over time in an effort to meet the National Coordinating Council for Medication Error Reporting and Prevention recommendation to discontinue the use of abbreviations in practice.

Until this can be achieved, all abbreviations and unclear orders or prescriptions should be questioned to avoid errors and the possibility of harm to patients.

Medication errors should be reported to the USP reporting programs so that tables can be updated and used as valuable resources for healthcare practice.

Medication Safety Pocket References of this resource are available for purchase by calling Customer Service at 1-800-227-8772.


The USP Quality Review is a publication of the USP Center for the Advancement of Patient Safety. USP operates two complementary error reporting programs: the USP Medication Errors Reporting Program, presented in cooperation with the Institute for Safe Medication Practices, and MEDMARX. For information on how to report errors, visit www.usp.org/hqi/patientSafety or call 1-800-23-ERROR (1-800-233-7767).