The Institute for Safe Medication Practices (ISMP) has released updated recommendations regarding conventions used to communicate medical information that can be misinterpreted. All items on the 2024 List of Error-Prone Abbreviations, Symbols, and Dose Designations were reported through ISMP’s national, voluntary error reporting program and have been involved in harmful or potentially harmful medication errors.
ISMP emphasizes that these abbreviations, symbols, and dose designations should NOT be used in verbal, handwritten, or electronic communications. This includes internal communications; verbal, handwritten, or electronic prescriptions; handwritten and computer-generated medication labels; drug storage bin labels; medication administration records; and screens associated with pharmacy and prescriber computer order entry systems, automated dispensing cabinets, smart infusion pumps, and other medication-related technologies.
“Healthcare organizations are encouraged to review the revised list to see if their internal “Do Not Use” lists require updating as well,” says Ann Shastay, MSN, RN, AOCN, Senior Manager, ISMP Publications.
“ISMP’s list points out abbreviations, symbols, and dose designations that also are included on the Joint Commission’s “Do Not Use” list to offer a complete resource for easy reference.”
Some of the changes to the 2024 list include:
- When a dose is being measured in nanograms, do not use “nanog” as an abbreviation. Use the full spelled-out word instead.
- For intranasal medications, do not use “NAS” as an abbreviation. Use the full spelled-out word instead.
- When a medication is intended to be used nightly at bedtime, do not use “nightly” or “HS” to mean at bedtime. Use QHS or qhs instead.
- When indicating a half tablet, do not use reduced font-size fractions. Use text instead and avoid using fractions or decimals.
- If a slash mark is needed to separate doses, do not use “per.” Use “and” instead.
For a copy of the current ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations, visit: List of Error-Prone Abbreviations | Institute For Safe Medication Practices (ismp.org)