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ISMP

Draft Guidelines for the Safe Electronic Communication of Medication Information
Safe presentation of drug nomenclature and dose expressions

  1. List all medication-related products by generic name using all lowercase letters (unless using tall man letters as mentioned in item #8) as the primary expression of drug nomenclature, ensuring that each matches US Food and Drug Administration (FDA)-approved nomenclature so that electronic medication records agree with all package labels.
  2. Do not include the salt of the chemical when expressing a generic drug 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., US Pharmacopeial Convention [USP]-approved abbreviations such as K [potassium], Na [sodium], HBr [hydrobromic acid], and HCl [hydrochloric acid]), it should follow the drug name, not precede it.
  3. As appropriate, list associated brand names in a requisite field using an uppercase first letter (unless using tall man letters). Although the use of all uppercase letters is a standard convention for trademarks, mixed-case and lowercase letters are more unique and distinguishable than all block-like uppercase letters, which look similar especially in low lighting.1 Trademark symbols (e.g., TM, ®) should not be used.
  4. Express suffixes that are part of the drug name (e.g., SR, CD, CR) within both the generic name field and the brand name field (e.g., diltiazem CD, Cardizem CD).
  5. Do not abbreviate drug names (e.g., MTX for methotrexate has been misunderstood as mitoXANtrone; MSO4 for morphine sulfate has been misinterpreted as magnesium sulfate).
  6. Do not use outdated terminology when referring to medications or solutions (e.g., “heparin lock flush” for saline lock) or medical jargon that may not be as clear as familiar lay terms (e.g., “ophthalmic” and “otic” can be more clearly expressed as “eye” and “ear”).
  7. Avoid using drug protocol acronyms (e.g., CVP) without defining the protocol (cyclophosphamide, vinCRIStine, predniSONE) at least once within the electronic communication.
  8. Use tall man bolded letters (e.g., DOBUTamine and DOPamine) to help distinguish look-alike products on screens to minimize the risk of selecting the wrong product when medication names appear alphabetically in look-up lists. See www.ismp.org/Tools/tallmanletters.pdf for FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters. Pharmaceutical manufacturers are required to use tall man lettering for drug names on the FDA list.
  9. Avoid the use of known error-prone abbreviations, symbols, and dose designations, including those on the ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations (www.ismp.org/Tools/errorproneabbreviations.pdf) that may cause confusion in electronic formats. Examples include:
  • Do not use trailing zeros when expressing medication/solution doses (e.g., use 5 mg, never 5.0 mg).
  • Use leading zeros for doses less than 1 measurement unit (e.g., 0.3 mg, never .3 mg).
  • Spell out the word “units.” Never use the abbreviation U, which easily can be mistaken as a zero, causing a 10-fold overdose. Never abbreviate international units as IU, which has been confused as IV (intravenous); this measure can be expressed as “units” alone.
  • Include properly spaced commas for dose numbers expressed in thousands or millions (e.g., 5,000 units).
  • Express weights and measures in a standard fashion and use USP standard abbreviations for dosage units as follows:

    (1) cm = centimeter
    (2) m (lowercase) = meter
    (3) kg = kilogram
    (4) g = gram
    (5) mg = milligram
    (6) mcg = microgram
    (do not use the Greek letter mu [µ], which has been misread as mg)
    (7) L (uppercase) = liter
    (8) mL (lower-/uppercase) = milliliter
    (do not use cc which has been misread as U or the number 4)
    (9) mEq = milliequivalent
    (10) mmol = millimole

  • Do not include a period after dose designation abbreviations (e.g., mg.).
  • Do not use apothecary system designations or symbols (e.g., grains, drams, minims), or household measurements (e.g., teaspoon,
  • Do not use IN as an abbreviation for intranasal (may be confused with IV or IM); use “intranasal” or “NAS.”
  • Do not use IT as an abbreviation for intrathecal (may be confused with other routes such as, intratracheal, intratumor, inhalation therapy, intratympanic); always spell out “intrathecal.”
  • Do not use the abbreviations o.d., OD, q.d., QD, or q1d for daily; spell out the word “daily.”
  • Do not use the abbreviations AD, AS, AU, OD, OS, and OU, to direct into which ear(s) or eye(s) to instill a medication; write out left ear, right eye, and so on.
  • Do not use the abbreviations q.o.d. or QOD for every other day; spell out “every other day.”
  • Do not use < or > signs; spell out the intended terms “less than” or “more than.”

See item #16 for a recommendation to provide adequate space in corresponding fields so these abbreviations do not need to be used.

  1. Use the typical smaller font for fractions (i.e., ½ not 1/2) to express a partial tablet.
  2. 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 the dosage form (e.g., timolol [Timoptic if brand dispensed] 0.5% ophthalmic solution; diazepam 5 mg tablet). When the strength and dose differ, also list the amount needed for the dose (e.g., propranolol 5 mg [½ x 10 mg] tablet) on the eMAR.
  3. When the drug name, strength/dose, and the unit of measure appear together, require a space between the drug name and strength/dose (e.g., propranolol20 mg has been misread as 120 mg), and between the dose and unit of measure (10Units has been misread as 100 Units).
  4. Include the name(s) of the drug and the patient-specific dose (not just the strength dispensed) on the same line/entry on eMARs. Avoid entries where the name of the drug and available dosage strength are on the first line, and the patient-specific dose is on the next line.
  5. List the most commonly used or preferred drug, strength, and dose first, if multiple drugs, strengths, and doses are available from which to choose.

Design features that support safe communication

  1. Use easy-to-read, larger size fonts not densely compressed when expressing electronic text.1 Familiar sans serif fonts without embellishments are preferred. However, serifs do not matter as long as the font style is not extreme or unusual.
  2. Provide adequate space for items in data fields used to communicate drug names, dosing units, routes of administration, and frequencies. Two or three character fields force the use of potentially dangerous abbreviations.
  3. If numbers are needed to sequence medication orders, provide adequate space between the numbers and the drug name to prevent misinterpretation of the sequencing number as the medication dose.
  4. Provide a field to enter the purpose/indication for all medications communicated electronically. Require entry of the purpose/indication for the following types of medication orders: all as needed (PRN) medications; look-alike products (www.ismp.org/Tools/confuseddrugnames.pdf) that are known to be problematic (few look-alike name pairs are used for the same purpose); and medications that have different dosing based on the indication (e.g., desmopressin for hemophilia or diabetes insipidus) or have multiple indications not included in the 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 drug’s indication reduces the risk of improper drug selection and offers clues to proper dosing when a medication has an indication-specific dosing algorithm.
  5. Require entry of the minimum components of a complete medication order or prescription (drug name, metric dose, frequency, route, indication). Do not allow doses prescribed only by volume, number of tablets, or number of vials/ampuls (exceptions include combination liquid medications available in a single concentration, eye and ear drops, creams and ointments, liquid multivitamins). Do not permit entry of range orders without objective measures to determine the correct dose.
  6. To prevent the risk of misinterpretation, do not allow the components of a complete medication order or prescription to be created using a combination of both discrete fields and free-text fields (which could conflict or lead to misinterpretation). Limit the need for free-text entries in e-prescribing and CPOE systems by providing a “special instructions” field with a menu of choices related to common precautions for specific drugs (e.g., patient assessments, antidotes, avoidance of concomitant medications). 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 eMARs).
  7. Provide users with ways to emphasize medication- or patient-related warnings or other important clinical notes related to prescribed medications (e.g., upper- and lowercase letters, contrasting color, bolding, italicizing, choice of fonts, audible alerts). When appropriate, warning statements should be presented in the active voice using affirmative statements instead of negative statements to ensure people understand the meaning of the hazard even if they don’t read every word.1 For example, “For Oral Use Only” should be used instead of “Not for IV Use,” which a practitioner could misread as “IV Use” if viewing just a portion of the warning.
  8. Provide users with the ability to search by brand name, generic name, short name, or mnemonic, and link all means of accessing a name to default to a generic name. Also, organize generic and brand names by dosage form in look-up tables (e.g., multiple gentamicin products should be organized by parenteral injection, ophthalmic solution, cream, and other dosage forms).
  9. 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).
  10. Provide the capability to link all closely associated drug therapies so that they appear sequentially together on profile screens and eMARs (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.
  11. 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 intravenous (IV) route of administration.
  12. Provide a mechanism to facilitate safe order entry of complex medication regimens (e.g., chemotherapy, electrolyte solutions, parenteral nutrition) or drugs that require a tapering dosing schedule (e.g., steroids) so that the orders appear clearly and in a logical sequence, and include all required elements (which may be different than for routine medications).
  13. For weight-based/body surface area-based pediatric medication orders, include required fields for both the mg/kg dose (or mg/kg/hour, mcg/kg/min, mg/m2, or similar weight-based or body surface area-based dosing formula) and the total calculated dose.
  14. Provide a mechanism to place medication orders on hold under specified conditions, and to alert users at specified times to remind them that doses have been held.
  15. See ISMP guidelines for designing medication labels generated from electronic systems for use in the acute care and community pharmacy settings (www.ismp.org/Tools/guidelines/default.asp).

Prompts for patient information closely related to medication use

  1. Provide fields that require electronic documentation of patient allergies (including food allergies) and associated reaction in a format where the allergy and reaction appear next to one another, prior to the entry of medication orders (except in emergencies).
  2. Allow only metric measurements of patient height (in cm only) and weight (in kg only [or grams for low birth weight infants]), and include a field to document the date the weight was collected.

Other topics for which further investigation and standards are needed

  1. If mnemonics or short names continue to be used, standards are needed that allow practitioners to access a particular medication listing without entering the full name.
  2. Use human factors data to select the appropriate character, text, and colors to use with electronic displays of information. For example, the contrast ratio for alphanumeric characters/text to the self-luminous computer screens or displays should not be below 7:1. Never display pure red text on a pure blue background or vice versa; never use pure blue or red text on a black background; and never use pure blue for text or fine details on electronic displays.2
  3. A standard process is needed for expressing combination and compounded products, including products that are often referred to by coined names (e.g., banana bag, magic mouthwash). Currently, coined names can be used if the contents of the product are standardized and available for reference to prescribers, pharmacists, and nurses.

References

  1. Wogalter MS, ed. Handbook of Warnings. Mahwah, NJ: Lawrence Erlbaum Associates; 2006.
  2. FAA human factors: Visual displays. Federal Aviation Administration (FAA) Web site. www.hf.faa.gov/Webtraining/VisualDisplays/VisDisp1.htm

 

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