|ERROR-PRONE DRUG NAME ABBREVIATIONS|
The drug name abbreviations found in this table have been reported to the Institute for Safe Medical Practices (ISMP) through the ISMP Medication Error Reporting Program as being frequently misinterpreted and involved in harmful medication errors. These drug name abbreviations should never be used when communicating medical information; complete drug names should be used.
|APAP||acetaminophen||Not recognized as acetaminophen||Use complete drug name|
|ARA A||vidarabine||Mistaken as cytarabine (ARA C)||Use complete drug name|
|AZT||zidovudine (Retrovir)||Mistaken as azathioprine or aztreonam||Use complete drug name|
|CPZ||Compazine (prochlorperazine)||Mistaken as chlorpromazine||Use complete drug name|
|DPT||Demerol-Phenergan-Thorazine||Mistaken as diphtheria-pertussis-tetanus (vaccine)||Use complete drug name|
|DTO||diluted tincture of opium, or deodorized tincture of opium (Paregoric)||Mistaken as tincture of opium||Use complete drug name|
|HCI||hydrochloric acid or hydrochloride||Mistaken as potassium chloride (The “H” is misinterpreted as “K”)||Use complete drug name unless expressed as a salt of a drug|
|HCT||hydrocortisone||Mistaken as hydrochlorothiazide||Use complete drug name|
|HCTZ||hydrochlorothiazide||Mistaken as hydrocortisone (seen as HCT250mg)||Use complete drug name|
|MgSO4*||magnesium sulfate||Mistaken as morphine sulfate||Use complete drug name|
|MS, MSO4*||morphine sulfate||Mistaken as magnesium sulfate||Use complete drug name|
|MTX||methotrexate||Mistaken as mitoxantrone||Use complete drug name|
|NoAC||novel/new oral anticoagulant||No anticoagulant||Use complete drug name|
|PCA||procainamide||Mistaken as patient controlled analgesia||Use complete drug name|
|PTU||propylthiouracil||Mistaken as mercaptopurine||Use complete drug name|
|T3||Tylenol with codeine No. 3 (acetaminophen with codeine)||Mistaken as liothyronine||Use complete drug name|
|TAC||triamcinolone||Mistaken as tetracaine, Adrenalin (epinephrine), cocaine||Use complete drug name|
|TNK||TNKase||Mistaken as “TPA”||Use complete drug name|
|TPA or tPA||tissue plasminogen activator, Activase (alteplase)||Mistaken as TNKase (tenecteplase), or less often as Retavase (retaplase)||Use complete drug names|
|ZnSO4||zinc sulfate||Mistaken as morphine sulfate||Use complete drug name|
|“Nitro” drip||nitroglycerin infusion||Mistaken as sodium nitroprusside infusion||Use complete drug name|
|“Norflox”||norfloxacin||Mistaken as Norflex (orphenadrine citrate)||Use complete drug name|
|“IV Vanc”||intravenous vancomycin||Mistaken as Invanz (ertapenem)||Use complete drug name|
*Included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. For more information visit http://www.jointcommission.org.
Source: Institute for Safe Medication Practices. Error-Prone Abbreviations, Symbols, and Dose Designations. 2017.
Available at: https://www.ismp.org/recommendations/error-prone-abbreviations-list. Accessed June 23, 2020.
This article originally appeared on MPR