This poster provides examples of medication orders with ambiguous or difficult-to-read abbreviations as well as how they should be written out.
Resource Library
Whether you have experienced a medication error in your organization or you are proactively implementing prevention strategies, you are not alone. Thousands of organizations worldwide have relied on ISMP's resources for institutional change to reduce errors on a daily basis. These resources are developed from ISMP's review of reports through its national error reporting programs, peer-reviewed articles in its publications, and/or consensus gathering summits on topics pertinent to specific errors or hazards. ISMP offers a wide range of downloadable and easy to use resources. Many are free.
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It is essential that healthcare practitioners place a zero in front of decimal points in drug dosages to help prevent ten-fold overdoses. This poster emphasizes that without the zero, the decimal point is often overlooked, and provides an example.
Quick reference guide to ISMP’s list of high-alert medications, documented drugs with look-alike-sound-alike risk, and error-prone abbreviations, symbols, and dose designations. **Sold in packs of 5**
This poster presents sample drug orders with "q.d." and "q.i.d." that show how those abbreviations can be confused, and emphasizes that they be spelled out for greater clarity.
It is uncommon to need more than 2 or 3 tablets, capsules, vials, ampules, etc. to prepare a single dose of medication. This poster alerts healthcare professionals to this fact and urges verifying with a pharmacist medication doses that seem to require more than 2 or 3 of anything.
Crushing or splitting some oral medications may alter the intended effect and possibly result in patient harm. This poster provides a checklist of questions that healthcare practitioners should ask before they consider crushing or splitting medications.
Healthcare practitioners should use the exact metric weight when writing drug orders. This poster discourages prescribing only by volume or dosage limit, which can be ambiguous, and provides a correct sample order.
Healthcare practitioners should always prepare liquid oral medications in oral syringes. This poster emphasizes that the tips on oral syringes make it more difficult or impossible to accidentally administer the oral medication intravenously.
Verbal and telephone medication orders can be misheard, misunderstood, or mistranscribed. This poster gives healthcare practitioners a checklist for safe order communication.