Dangerous Error-Prone Prescription Abbreviations

As Maryland Pharmacy Error Attorneys, we have been following a recent report by The Institute for Safe Medication Practices (ISMP) about the danger of error-prone abbreviations and when it comes to writing a prescription—the fact that some shortcuts don’t save time, and can result in pharmacy error or injury.

According to the ISMP Error Alert article, nearly everyone in the healthcare industry uses shortcuts, like abbreviations and symbols, in an effort to save time when handwriting specifics for the prescription—including phrases, units of measure and words. Some shortcuts can in the end can be very time consuming, as they need to be checked and verified for accuracy on the receiving end. These verifications could also reportedly cause a greater chance for medication error than if the prescription was written out without abbreviations or symbols. The article claims that it is important to prevent future misunderstandings now, instead of waiting until medical abbreviations, dose designations or symbols lead to a patient injury.

The article lists a few common error-prone abbreviations, symbols and dosage misunderstandings that take more time for the pharmacist to check, and could cause medication mistakes:

• Some abbreviations that indicate the frequency of when to take the drug, can be difficult to understand, and can lead to error. In one prescription for “Penicillin VK 500 mg Q1D X 7D,” the physician accidentally typed “Q1D” (once a day) instead of “QID” (four times a day). The pharmacist realized the mistake, and that the patient was supposed to be taking the penicillin four times a day for seven days (7D). Another example of frequent error comes in the abbreviation for “D” (days), where it can also be mistaken for “doses.”

• Many abbreviation mistakes come up in prescribing, with the use of “q.d.” (every day). When written in cursive, the loop of the “q” can cause the notation to read as “q.i.d.” (four times daily), or even “q.o.d.” (every other day). The article recommends writing out the directions “daily” and “every other day” instead of risking misinterpretations with abbreviations.

• Another common pharmacy error can happen with the abbreviation “AD” (right ear). In one case, a pharmacist who was reportedly tired of writing out “as directed,” began to abbreviate that term as “AD.” The oral liquid prescription was then transcribed to read “one teaspoon three times daily in right ear.” When handwritten, a lowercase “a” can also easily be confused with an “o.” So a patient could be instructed to use medicine in the right eye, “OD” instead of the prescribed right ear, “AD.” The ISMP Error Alert Report recommends that the best practice is to always write out all directions for left and right eye and ear, to avoid medication error, or patient injury.

In a related blog, our lawyers discussed other ISMP Medication error cases, and what patients and the healthcare industry can do to prevent pharmacy misfill, or medication mistakes.

At Lebowitz and Mzhen, LLC, our attorneys are committed to representing victims of medical mistakes and their loved ones, in Maryland and the Washington D.C. area. Contact us today for a free consultation.

Shortcuts Don’t Save Time, ISMP Error Alert, November 2009

Related Web Resources:

Institute for Safe Medication Practices, (ISMP)

Council Recommendations: Promoting the Safe Use of Suffixes in Prescription Drug Names, National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

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