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 medication information.

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 of information.

To jumpstart this important endeavor, we’ve 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 mg)
(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 sulfate).

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, and frequencies. 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; look-alike products 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 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.

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 product’s 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 selected (e.g., 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 the medications.

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 day’s records).

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 during electronic 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.