From the February 20, 2003 issue
Among its many benefits, electronic communication of
medication orders allows for more accurate conveyance of information
than handwritten formats. However, if the conventions used
to communicate electronic information are not considered carefully,
computerized order processing actually may contribute to medication
errors. For example, in a previous issue (ISMP Medication Safety Alert! Eliminating dangerous abbreviations and dose
expressions in the print and electronic world. Feb 20, 2002)
we detailed how poorly conceived abbreviations or dose expressions
used in computer software can make it difficult to differentiate
between 100U and 1000, 1.0 and 10, or look-alike drug names.
To avoid problems, healthcare technology vendors need a set
of accepted standards for the electronic communication of
As a start, standards-setting organizations need to be
actively involved in nomenclature issues as they relate
to electronic systems, recognizing the current limitations
in electronic fields and its effect on information as it
appears on screens, labels and reports. But as we await
efforts by standards-setting organizations, health systems
should begin to develop guidelines to promote accurate electronic
communication. For medication-related communication, pharmacists
should take the lead, working in cooperation with the information
technology department and others involved in developing,
reviewing and approving medical communications. Recommendations
from credible sources such as FDA, USP, ISMP and others
should be sought to identify potentially confusing abbreviations,
dose designations, dosage forms, medication names, and other
problems that may be unique to electronic communication
To jumpstart this important endeavor, weve begun
to compile a list of suggested guidelines that we plan to
share with standards-setting organizations and other professional
associations. The scope of the guidelines is narrow and
covers only issues that deal with how information about
prescribed medications is presented and communicated in
electronic formats. Although equally important, other issues
related to functionality of electronic systems and how clinicians
use them will be covered at a later time. The suggested
guidelines to date are listed below and are posted on our
web site at www.ismp.org. The draft guidelines also will
be posted on the ASHP CPOE listserve. Right now, our list is incomplete
and certain portions are expected to attract discussion
about their benefits and limitations. We welcome your help
in shaping the guidelines and encourage you to openly share
your comments and suggestions on this very important issue
(send comments to us or post on the ASHP CPOE listserv).
Draft Guidelines For Safe Electronic Communication
of Medication Orders
Safe presentation of drug nomenclature and dose expressions
in electronic systems
1. List all products by generic name (use lower case letters
unless using "tall-man" letters as mentioned in
item #7) as the primary drug nomenclature, ensuring that
each matches FDA-approved nomenclature so that all package
labels agree with medication records.
2. Do not include the salt of the chemical when expressing
a generic name unless there are multiple salts available
(e.g., hydroxyzine hydrochloride and hydroxyzine pamoate).
If the salt is used as part of the name (e.g., USP approved
abbreviations such as K, Na, HBr, and HCl), it should follow
the drug name, not precede it (e.g., warfarin Na, not Na
warfarin, which can look like "no warfarin").
3. As appropriate, list associated brand names in a requisite
field. When used, present brand names in upper case letters
(e.g., LANOXIN, LASIX) to differentiate them from generic
names (use of all uppercase letters is a standard for trademarks
throughout the pharmaceutical industry). Trademark symbols
should not be used [e.g., TM or (r)].
4. Express suffixes that are part of the brand name (e.g.,
SR, SA, CR) within both the generic name field and the brand
name field (e.g., diltiazem XT and DILTIA XT).
5. Avoid use of all potentially dangerous abbreviations
and dose expressions (Click here to see list)
including the following:
a. Do not use trailing zeros (5 mg, never 5.0 mg).
b. Use leading zeros for doses less than one measurement
unit (0.3 mg, never .3 mg).
c. Spell out the word UNITS. If adequate space is not available
(see item #10), use the abbreviation UT (never U, which
easily can be mistaken as a zero, causing a 10-fold overdose).
d. Include properly spaced commas for dose numbers expressed
in thousands (e.g., 5,000 units). Avoid using M as an abbreviation
for thousands (e.g., 5 M units), which has been mistaken
as million. Use the word thousand for larger doses in the
hundreds of thousands (e.g., 150 thousand rather than 150,000).
Use the word million for doses expressed in millions (e.g.,
1 million units) to avoid possible misplacement of commas
and misreading the dose if the commas are not seen correctly
with such large numbers.
e. Express weights and measures in a standard fashion and
use USP standard abbreviations for dosage units as follows:
(1) m (lower case) = meter
(2) kg = kilogram
(3) g = gram
(4) mg = milligram
(5) mcg = microgram
(do not use the Greek letter mu which has been misread as
(6) L (upper case) = liter
(7) mL (lower/upper case) = milliliter (do not use cc which
has been misread as U or the number 4)
(8) mEq = milliequivalent
(9) mmol = millimole
6. To avoid confusion, do not abbreviate drug names (e.g.,
MTX for methotrexate has been misunderstood as mitoxantrone;
MSO4 for morphine sulfate has been misinterpreted as magnesium
7. Use tall-man letters (e.g., hydrOXYzine
and hydrALAZINE) to help distinguish look-alike products
on screens and reports to minimize the risk of selecting
the wrong product when medication names appear alphabetically
in look-up lists (see www.ismp.org/newsletters/acutecare/articles/drugnames.html
for an up-to date list of generic drug names for which the
FDA has required the use of tall-man lettering
by pharmaceutical manufacturers).
8. When the drug name, strength, dosage form and dosage
units appear together, list the generic name first, followed
by brand name, strength,
dose (if different than strength) and dosage form (e.g.,
timolol [TIMOPTIC] 0.5% ophthalmic solution; diazepam [VALIUM]
5 mg tablet). When the strength and dose differ, also list
the amount needed for the dose (e.g., propranolol [INDERAL]
5 mg [1/2 x 10 mg] tablet).
9. When the drug name, strength, dosage form and dosage
units appear together, avoid confusion by providing a space
between them (e.g., propranolol20 mg has been misread as
120 mg and 10Units has been misread as 100 Units).
Design features for electronic order entry systems (pharmacy
and prescriber) that support safe communication of orders
10. Provide adequate space for items in data fields used
to communicate drug names, dosing units, routes of administration,
Two or three character fields force use of potentially dangerous
abbreviations [QD for daily often misread as QID;
QOD for every other day often misread as QID; U for
units often misread as a zero or four]. Seeing the
use of dangerous abbreviations in electronic formats may
encourage practitioners to use them.
11. Provide a field that requires entry of the purpose
for the following types of medication orders: all prn medications;
that are known to be problematic (few look-alike name pairs
are used for the same purpose); and medications that have
different dosing for varying indications or have multiple
indications not in approved labeling (e.g., most prescriptions
for gabapentin are for off-label uses such as neuropathic
pain syndrome, generalized anxiety, social phobia, migraine
therapy). Communicating the drugs indication reduces
the risk of improper drug selection and offers clues to
proper dosing when a medication has an indication-specific
12. Provide users with ways to emphasize medication or
patient related warnings or other important clinical notes
related to prescribed medications (e.g., upper and lower
case letters, contrasting color, bolding, italicizing, flashing
information, choice of fonts, audible alerts).
13. Provide users with the ability to search by brand name,
generic name, synonym, or mnemonic, and link all means of
accessing a name to a generic name default. Also organize
generic and brand names by dosage form in look-up tables
(e.g., multiple gentamicin products should be
organized by parenteral, ophthalmic solution, cream, and
other dosage forms).
14. Provide the ability to clearly communicate medications
prescribed for specific, non-routine administration times
or under certain conditions (e.g., with dialysis, while
NPO, until tolerating liquids, prior to surgery).
15. Provide a field that requires entry of the products
dosage form (e.g., tablets, capsules).
16. Provide the capability for users to link medications
only to the appropriate routes of administration available
for each drug. For example, vincristine injection should
link only to the IV route of administration.
17. Provide required dose fields for users to designate
the actual pre scribed dose after product strength has been
selection of NPH insulin 100 units/mL requires a dose field
to enter the prescribed dose in units).
18. Provide the generic name on all computer-generated
labels and reports, including computer-generated MARs. Provide
the option for listing brand names.
19. Provide a mechanism to facilitate safe order entry
of complex medication regimens (e.g., chemotherapy, sliding
scale insulin) and medications that require a tapering dosing
schedule (e.g., steroids) so that the orders appear clearly
and in a logical order for those who dispense and administer
20. Provide the capability for clinicians to select the
time or date to begin drug administration, regardless of
when the order was entered, so that it appears on profile
screens and computer-generated MARs on the correct date/time
(e.g., a daily medication order entered after the typical
0900 administration time could appear on the current days
21. Provide the capability to link all closely associated
drug therapies so that they appear sequentially together
on medication profile screens and computer-generated MARs
(e.g., orders for PCA should be linked to corresponding
orders for nausea, itching, and breakthrough pain), and
also to facilitate discontinuation of associated therapies
when the primary therapy is discontinued.
22. Provide a mechanism to place medication orders on hold
under specified conditions, and to alert users at specified
times while a medication is on hold.
23. To prevent the risk of misinterpretation, limit the
potential for free-text entries in CPOE systems. Allow full
capability of free text entries in the pharmacy computer
system to facilitate communication of important information
among pharmacists (via pharmacy computer screens) and nurses
(via computer-generated MARs).
Other communication-related topics for which further
investigation and standards are needed
24. Standards are needed for mnemonics or short names that
allow practitioners to access a particular medication listing
without entering the full name.
25. Standards are needed for the use of fonts (size and
style) and colors that facilitate clarity of information
presented on computer
screens and in printed materials derived from electronic
databases (e.g., labels, reports).
26. Consideration must be given to the role that symbols
and certain letter characters may play in creating errors
communication. For example, slash marks and hyphens have
been misread as the number one, and symbols for more and
less than have been misinterpreted opposite from intended.
Also, the letter O can be misread as a zero (0), the letter
z as the number 2, and a lower case L (l) as the number
1 or the letter i (I).
Right now, our list is incomplete and certain portions
are expected to attract discussion about their benefits
and limitations. We welcome your help in shaping the guidelines
and encourage you to openly share your comments and suggestions
on this very important issue (send comments us or post on the ASHP CPOE listserv).
We thank Ron Mortus, Regional Director of Pharmacy,
Cleveland Clinic Health System, Cleveland, OH, for helping
us begin this compilation and appreciate the assistance
and suggestions made by those who reviewed the initial draft.