MSA! Articles

Draft Guidelines for the Safe Communication of Electronic Medication Information

Electronic health records (EHRs), computerized prescriber order entry (CPOE) systems, electronic medication administration records (eMARs), and electronic prescribing (e-prescribing) systems are health information technologies (HIT) being widely adopted by healthcare providers in a national effort to improve the quality and safety of healthcare.1 According to a 2014 national survey, more than 80% of US hospitals have implemented inpatient CPOE systems with clinical decision support, 93% have implemented eMARs, and 94% have partially (60%) or fully (34%) implemented EHRs.2 In the outpatient setting, more than 94% of US pharmacies are accepting electronic prescriptions (eRxs) from more than half of prescribers who are using these systems.3,4  The most substantial increases in implementation have occurred during the past 3 to 4 years due to federal incentives. As of July 2015, more than $20.9 billion in incentives have been paid to Medicare and Medicaid healthcare providers for HIT implementation that demonstrates meaningful use.5

Examples of hazards

While EHRs, CPOE, eMARs, and e-prescribing systems have quickly become a mainstay in healthcare, their introduction has brought about significant changes in how medications are prescribed, dispensed, and administered. If the conventions used to communicate this information electronically are not carefully considered, these forms of HIT and others may actually contribute to medication errors rather than mitigate the risk.

In our newsletters, we have often detailed how poorly conceived abbreviations or dose expressions used in HIT software can make it difficult to differentiate between 100U and 1000, 1.0 and 10, or look-alike drug names. We have described the misidentification of alphanumeric symbols with electronic communication and provided a table with dozens of examples, including how the lowercase letter l looks exactly like the numeral 1 or the uppercase letter I, and the uppercase letter O looks just like the numeral 0.

We have described electronic communication errors caused by restricted character spaces or truncated listings that made it impossible to communicate the full name and dose of a medication (e.g., an order for NovoLOG Mix 70/30 FlexPen appeared as “NovoLog Mix FlexPen 70” due to a limited number of characters per field). We have tied the size limitation of drug inventory fields with forcing the use of unsafe drug name abbreviations (e.g., APAP, HCTZ) or truncated names for investigational drug name codes. We have also reported errors associated with a failure to maintain a space between the drug name, dose, and units of measure. For example, Amaryl2 mg has been misread as 12 mg.

We have reported that some HIT software platforms do not allow the use of tall man letters for dissimilar parts of drug name pairs with look-alike names. We have provided numerous examples of unsafe HIT defaults that are used to prepopulate fields or to populate fields with missing data—a default to teaspoons rather than mL for oral liquid medications is an example. We have pointed out that large doses without properly placed commas have been confused—for example, 100000 has been mistaken as 10000 (10,000) or 1000000 (1,000,000). We have provided examples of misinterpretations of symbols, dose designations, and abbreviations known to be error-prone (e.g., QD, tPA, > and <, IT) when used in electronic communications. Some of these errors have led to patient harm. 

Guidelines for electronic medication information

To avoid errors, HIT vendors and users need a set of accepted guidelines related to the safe presentation of electronic data associated with medication information. There are quite a few standards already promulgated for various aspects of HIT, particularly related to the exchange, integration, interoperability, sharing, security, and retrieval of HIT. These standards have arisen from various national-level sources, including Health Level Seven International (HL7), Digital Imaging and Communications in Medicine (DICOM), National Uniform Billing Committee (NUBC), The Accredited Standards Committee (ASC) X12, National Council for Prescription Drug Programs (NCPDP), National Committee on Vital and Health Statistics (NCVHS), the Health Insurance Portability and Accountability Act (HIPAA), the federal EHR Incentive Program, and Healthcare Information and Management Systems Society (HIMSS) Electronic Health Record Association (EHRA).6,7 However, these and other standards-setting sources have not compiled a robust list of guidelines to promote the safe communication of electronic medication-related information.    

To address this need, ISMP has compiled a set of Draft Guidelines for the Safe Electronic Communication of Medication Information.  We examined the literature and other credible sources to identify potential confusion that is unique to electronic communication or that affects both paper and electronic records, and then developed the draft guidelines. The scope of the draft guidelines is narrow and covers only issues that deal with how information about medications is communicated in electronic formats, including EHRs, CPOE systems, eMARs, pharmacy computer systems, e-prescribing systems, and other displays of electronic health information when using barcode scanning systems, smart infusion pumps, and automated dispensing cabinets.

After the comment period, we plan to finalize the guidelines and submit them to The Office of the National Coordinator for Health Information Technology (ONC HIT), which has been given responsibility for the harmonization of standards for HIT from multiple sources. We also plan to share the guidelines with HIT vendors, standards-setting organizations such as The Joint Commission and the Centers for Medicare & Medicaid Services, and HIT-related professional organizations. We hope vendors will work cooperatively with their user facilities to improve the safety of the electronic communication of medications.


  1. Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007;14(4):415-23.
  2. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2014. Am J Health-Syst Pharm. 2015;72(13):1119-37.
  3. Villasenor S, Piscotty RJ Jr. The current state of e-prescribing: Implications for advanced practice registered nurses [published online ahead of print May 5, 2015]. J Am Assoc Nurse Pract. doi:10.1002/2327-6924.12263.
  4. Hincapie AL, Warholak T, Altyar A, Snead R, Modisett T. Electronic prescribing problems reported to the Pharmacy and Provider ePrescribing Experience Reporting (PEER) portal. Res Social Adm Pharm. 2014;10(4):647–55.
  5. Centers for Medicare & Medicaid Services. Data and program reports; EHR incentive programs. Updated August 12, 2015. 
  6. Hoffman S, Podgurski A. Finding a cure: The case for regulation and oversight of electronic health record systems. Harv J Law  Technol. 2008; 22(1):104-64.
  7. Segal M, Corley S, Burchell L, et al. Medicare and Medicaid programs; Electronic Health Record Incentive Program—Modifications to meaningful use in 2015 through 2017. HIMMS Electronic Health Record Association. June 15, 2015. 

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