Additional Considerations

Risky abbreviations
Prescribers should avoid the use of abbreviations, including those for drug names, because they can frequently be misunderstood.

Some examples of risky abbreviations compiled by the Institute for Safe Medication Practices (ISMP) include:

• µg (microgram)—can be mistaken for “mg” when handwritten and should be written as mcg
• q.d. or QD (every day)—can be mistaken as q.i.d., especially if the period after the “q” or the tail of the “q” is misread as an “i”; “daily” or “every day” preferred
• IU (international unit)—can be misread as IV; “units” preferred
• No zero before decimal point in dosage, for example, .5 mg (for 0.5 mg)—can be misread as 5 mg

The following examples of drug names that have been misinterpreted illustrate the importance of spelling out a medication’s complete name:

• AZT (zidovudine) can be misinterpreted as “azathioprine”
• CPZ (Compazine) can be misinterpreted as “chlorpromazine”
• DPT (diphtheria-pertussis-tetanus) can be misinterpreted as “Demerol-Phenergan-Thorazine”
• HCT (hydrocortisone) can be misinterpreted as “hydrochlorothiazide”
• HCTZ (hydrochlorothiazide) can be misinterpreted as “hydrocortisone”
• MgSO₄ (magnesium sulfate) can be misinterpreted as “morphine sulfate”
• MSO₄ (morphine sulfate) can be misinterpreted as “magnesium sulfate”
• TAC (triamcinolone) can be misinterpreted as “tetracaine, adrenalin, cocaine”
• 5-ASA (5-aminosalicylic acid) can be misinterpreted as “five tablets of aspirin”

“High-alert” medications
While most medications have a large safety margin, a small number have a high risk of causing injury when misused. The term “high-alert medication” is intended to draw attention to this characteristic so that everyone involved in using high-alert medications will treat them with the necessary care. Although errors may or may not be more common with these drugs than with others, the consequences when errors do occur may be serious. For a complete listing of high-alert medications, go to http://www.ismp.org/Pages/ismp_faq.html.

Confirmation bias
Confirmation bias refers to a type of selective thinking in which a person selects for what is familiar or expected, rather than what is actually there. Many errors occur when a practitioner, being familiar with so many products, expects to see a particular product and, because of that expectation, in fact selects one with a similar name.

Independent double-checks
While technologies like computerized prescriber order entry and bar-coding systems have great potential to detect human error, manual redundancies (like independent double-checks) still play an important role in error detection. Studies show that manual redundancies detect about 95 percent of errors. Independent double-checks serve two purposes: to prevent errors from reaching a patient and to draw attention to the systems that allow human error to be introduced. Independent double-checks should be done on error-prone processes such as the use of high-alert medications.

Patient education
Patients must receive ongoing education from physicians, pharmacists and nurses about the brand and generic names of medications they are receiving, their indications, usual and actual doses, expected and possible adverse events, drug or food interactions and how to protect themselves from errors. Patients can play a vital role in preventing medication errors if pharmacists encourage them to ask questions about their medications before they are dispensed.