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The Pattern of Abbreviation Use in Prescriptions: A Way Forward in Eliminating

Error-Prone Abbreviations and Standardisation of Prescriptions

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Current Drug Safety, 2014, 9, 000-000 1

The Pattern of Abbreviation Use in Prescriptions: A Way Forward in

Eliminating Error-Prone Abbreviations and Standardisation of
Prescriptions
N.R. Samaranayake*,1,2, P.R.L. Dabare2, C.A. Wanigatunge3 and B.M.Y. Cheung1

1
Department of Medicine, Faculty of Medicine, The University of Hong Kong, Hong Kong
2
Department of Medical Education and Health Sciences, Faculty of Medical Sciences, University of Sri
Jayewardenepura, Sri Lanka
3
Department of Pharmacology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka

Abstract: Introduction and Objectives: Inappropriate abbreviations used in prescriptions have led to medication errors.
We investigated the use of error-prone and other unapproved abbreviations in prescriptions, and assessed the attitudes of
pharmacists on this issue.
Methods: A reference list of error-prone abbreviations was developed. Prescriptions of outpatients and specialty clinic
patients in a teaching hospital in Sri Lanka were reviewed during one month. An interviewer administered questionnaire
was used to assess attitudes of pharmacists.
Results: 3370 drug items (989 prescriptions) were reviewed. The mean (standard deviation) number of abbreviations per
prescription was 5.9 (3.5). The error-prone abbreviations used in the hospital were, µg (microgram), mcg (microgram), u
(units), cc (cubic centimeter), OD (once a day), @ sign, d (days/daily), m (morning) and n (night), and among all
prescriptions reviewed, they were used at a rate of 17.4%, 0.1%, 1.9%, 0.2%, 0.2%, 4.9%, 23.5%, 4.4% and 15.8%
respectively. Among the 103 types of abbreviations observed, 71 were not standard acceptable abbreviations. Multiple
abbreviations were used to indicate a single drug item/ instruction (N = 7). The abbreviation ‘d’ was used to denote ‘daily’
as well as ‘days’. All pharmacists believed that using error-prone abbreviations will always (5.3%) or sometimes (94.7%)
lead to medication errors.
Conclusions: Error-prone abbreviations and many other unapproved abbreviations are frequently used in hospitals. There
is a need to educating health care professionals on this issue and introduce an in-house error-prone abbreviation list for
their guidance.
Keywords: 'Do Not Use' list, error-prone abbreviations, Medication errors, prescriptions; Sri Lanka, unapproved abbreviations

INTRODUCTION pharmacists, to determine the difficulties associated with

The use of inappropriate abbreviations in prescriptions
may alter intended therapeutic outcomes and even cause
unnecessary harm to patients [1, 2]. Many safety
organisations have cautioned this malpractice and have even
highlighted some abbreviations that are frequently associated
with medication errors [3-5]. Despite these warnings, error-
prone abbreviations continue to be used [6]. The rapid
evolvement of electronic prescriptions have minimised this
problem to an extent [7], but hand-written prescriptions will
continue to be used, especially in developing countries [8, 9].
Therefore eliminating error-prone abbreviations and
standardising acceptable abbreviations is an urgent need.
In order to achieve this goal, it is first important to
identify the types and frequencies of inappropriate
abbreviations used in prescriptions. Secondly, it is important
to assess the attitudes of prescription interpreters, mainly
*Address correspondence to this author at the Department of Medical
Education and Health Sciences, Faculty of Medical Sciences, University of
Sri Jayewardenepura, Sri Lanka; Tel: 00194714467919;
E-mail: nithushisamaranayake@yahoo.com
reading and interpreting abbreviations. Unfortunately,
abbreviations are not used consistently and may differ by
country, setting or hospital [10-13]. Therefore, even if
similar studies exist, these findings may not be completely
applicable to all settings.
Many safety organisations have introduced ‘Do Not Use’
lists; lists that specify error-prone abbreviations that should
be avoided by doctors when prescribing [3-5]. Although our
previous work has suggested that this intervention is
effective [14], the success would largely depend on
introducing a comprehensive error-prone abbreviation list
that would target inappropriate practices of a particular
setting. As the pattern of using abbreviations vary among
different settings, directly adopting error-prone abbreviation
lists from other countries may not always be appropriate.
Therefore we first compared error-prone abbreviations
lists introduced by several internationals safety organisations
[3-5, 15] in order to compile a comprehensive reference list.
Using this reference, we aimed to identify error-prone
abbreviations used in prescriptions of the study hospital. We
also aimed to identify other potentially dangerous
unapproved abbreviations (not listed as error-prone

1574-8863/14 $58.00+.00 © 2014 Bentham Science Publishers

2 Current Drug Safety, 2014, Vol. 9, No. 1
abbreviations), identify multiple abbreviations used to
denote the same drug or instruction, and to identify instances
where a single abbreviation has multiple intended meanings.
We then aimed to ascertain attitudes of pharmacists
regarding the use of inappropriate abbreviations in
prescriptions. Using this information, we aimed to determine
the suitability of developing an in-house error-prone
abbreviation list against directly adopting lists recommended
in other countries.
METHODS
The study was conducted in a university affiliated tertiary
care hospital (herein after referred to as the study hospital)
with 34 wards, 7 specialty units, 12 operating theaters and a
bed strength of 1073 beds. Apart from the in-patient care, the
hospital’s out-patient services include the operation of 35
specialty clinics, accident & emergency, trauma and out-
patient care department (OPD).
The pharmacy department is mainly divided as indoor
and outdoor pharmacies. The outdoor pharmacy dispenses
drugs to the clinic patients and OPD patients, while the
indoor pharmacy distributes drugs to the wards. As the
hospital adopts a ward-stock method of drug distribution,
pharmacists in the indoor pharmacy do not come into direct
contact with prescriptions. Therefore only prescriptions and
pharmacists related to the outdoor pharmacy were included
in this study. We included prescriptions dispensed to OPD
patients and 13 specialty clinics (medical, surgery,
cardiology, neurology, endocrinology, skin, diabetes,
peadiatrics, psychiatry, gastroenterology, cancer, asthma and
hypertension clinic).
THE STUDY PROCESS
Development of an Error-Prone Abbreviations Reference
List
Error-prone abbreviations introduced by the Institute of
Safe Medication Practices [3], the Joint Commission on
Accreditation of Healthcare Organizations of the USA [4],
Hospital Authority of Hong Kong SAR [15] and Australian
Commission on Safety and Quality in Healthcare [5] were
compared and a reference list of error-prone abbreviations
was prepared by the study pharmacists. The comparison of
error-prone and standard abbreviations introduced by
different safety organisations are shown in Table 1.
According to the comparison, the Institute of Safe
Medication Practices [3] and the Australian Commission on
Safety and Quality in Healthcare [5] introduced a wide list of
error-prone abbreviations compared to the lists introduced by
the Joint Commission [4] and the Hospital Authority of
Hong Kong. Of note, abbreviations ‘IU’ (international units),
‘QD’ (once daily), ‘QOD’ (every other day), ‘u’ (units),
trailing zero and lack of leading zero were highlighted by all
four lists. ‘µg’ (microgram) and ‘OD’ (once daily) were
highlighted in three lists. The reference list of error-prone
abbreviations developed for this study incorporated
abbreviations specified in all four lists (Table 2a). Two
clinical pharmacologists reviewed and endorsed the
reference list.
Samaranayake et al.
The Prescription Review Process
Abbreviations used in prescriptions were reviewed by
two study pharmacists and were recorded in a pre-
determined data collection form. Abbreviations used for
indicating drug names, instructions, route of administration
and frequencies were documented. The prescriptions were
randomly selected at any stage during the dispensing cycle.
Prescriptions applicable to the latest clinic date were
reviewed in patients who maintained a clinic book, and all
reviewed prescriptions were tagged to avoid selecting the
same prescription again. The audit was conducted for a
period of one month on weekdays. Conducting the study for
one month ensured that a representative sample of all clinic
prescriptions was included, as generally all clinic patients
revisit the clinic once a month. A sample of 50 prescriptions
was reviewed and recorded by both study pharmacists, the
records were compared and % of agreement was calculated
using the kappa value. Discrepancies were discussed and a
uniform method of interpreting prescriptions and recording
were agreed upon. This ensured that variances in the ability
to read and interpret handwritten prescriptions did not differ
among the two study pharmacists. Error-prone abbreviations
were determined according to the developed reference list.
Abbreviations that were not categorised as error-prone, but
did not comply with, the standard abbreviation list of the
Hospital Authority of Hong Kong (Table 2b), and the list of
acceptable terms or abbreviations of the Australian
Commission on Safety and Quality in Healthcare [5] were
grouped as ‘other unapproved abbreviations’. Abbreviations
that had more than one intended meaning and full names that
were represented by more than one abbreviation were also
noted.
Sample Size Determination
Approximately, 103,235 patients visit the outdoor
pharmacy every month and using a 5% margin of error, 95%
confidence interval and a 50% response distribution, 383
prescriptions were calculated as a representative sample for
review (Raosoft. Inc, 2004, Seattle, WA). The proportions of
prescriptions to be included from the OPD and the different
specialty clinics were determined based on the out-patient
and clinic attendance, and through expert opinion.
The Survey Process
To complement the prescription review process and
obtain qualitative data, a survey was conducted. An
interviewer administered questionnaire was developed and
all 19 pharmacists who were attached to the outdoor
pharmacy were invited for the survey. Demographic
information and attitudes on abbreviations were assessed in
the questionnaire. The English version of the questionnaire
was validated by five academic pharmacists (not included as
study participants) before conducting the survey. Each
question was validated on its relevance to the objective,
appropriateness of response options, clarity to the reader,
whether testing what was intended by researcher, and if re-
wording was needed, using a five point ordinal scale.
According to their comments, two questions were modified
The Pattern of Abbreviation Use in Prescriptions Current Drug Safety, 2014, Vol. 9, No. 1 3

Table 1. Comparison of Error-Prone Abbreviations Listed by Different Safety Organisations

Error-Prone Abbreviation Intended Meaning ISMP JCAHO HAHK ACSQH

µg Microgram ü ü ü

mcg Microgram ü ü

BID or bid Twice a day ü

AD, AS, AU Right ear, left ear, each ear ü

OD, OS, OU Right eye, left eye, each eye ü

OW Once week ü

p/f Per fortnight ü

BT Bedtime ü ü

cc Cubic centimeters ü ü

D/C Discharge or discontinue ü ü

e/ E Eye ü

gtt or gutte Drops ü

IJ Injection ü ü

IN Intranasal ü ü

IT Intrathecal ü

HS or hs Half-strength at bedtime, hours of sleep ü ü

IU** International units ü ü ü ü

o.d. or OD Once daily ü ü ü

OJ Orange juice ü ü

Per os By mouth, orally ü

Pulv Powder ü

q.d. or QD** Every day ü ü ü ü

q.h Every hour ü

qhs Nightly at bedtime ü ü

qn Nightly or at bedtime ü

q.o.d. or QOD Every other day ü ü ü ü

q1d Daily ü

q6PM, etc. Every evening at 6 PM ü ü

SC, SQ, sub q Subcutaneous ü ü

SL Sublingual ü

ss Sliding scale (insulin) or ½ (apothecary) ü ü

SSRI Sliding scale regular insulin ü ü

SSI Sliding scale insulin ü ü

i/d, i/D One daily ü ü

TIW or tiw Three times a week ü ü

TID Three times a day ü

U or u** Unit ü ü ü ü

UD As directed (“ut dictum”) ü

Ung Ointment ü

M or m Morning ü

N or n Night ü
4 Current Drug Safety, 2014, Vol. 9, No. 1 Samaranayake et al.

(Table 1) contd…..

Error-Prone Abbreviation Intended Meaning ISMP JCAHO HAHK ACSQH

Occ or oc Eye ointment ü

Mist Mixture ü

Trailing zero - ü ü ü ü

Lack of leading zero - ü ü ü ü

Large doses without properly placed commas 100,000 units 1,000,000 units ü ü

APAP acetaminophen ü

ARA A vidarabine ü

AZT zidovudine (Retrovir) ü

CPZ compazine (prochlorperazine) ü

DPT Demerol-Phenergan-Thorazine ü

DTO Diluted tincture of opium, or deodorized tincture of opium ü

HCl hydrochloric acid or hydrochloride ü

HCT hydrocortisone ü

HCTZ hydrochlorothiazide ü

MgSO4 magnesium sulfate ü

MTX methotrexate ü

PCA procainamide ü

PTU propylthiouracil ü

T3 Tylenol with codeine No. 3 ü

TAC triamcinolone ü

TNK TNKase ü

ZnSO4 zinc sulfate ü

“Nitro” drip nitroglycerin infusion ü

“Norflox” norfloxacin ü

“IV Vanc” intravenous vancomycin ü

x3d For three days ü ü

> and < Greater than and less than ü ü

/ (slash mark) Separates two doses or indicates “per” ü ü

@ At ü ü

& And ü ü

+ Plus or and ü ü

° Hour ü ü

.or. zero, null sign ü

MS Morphine sulphate or magnesium sulphate ü ü

MSO 4 Morphine sulphate ü ü

6/24 Every six hours ü

1/7 For one a day ü

½ Half ü

106 One million ü

ü, present ; ISMP, Institute of Safe Medication Practices; JCAHO, Joint Commission on Accreditation of Healthcare Organization; HAHK, Hospital Authority of Hong Kong;
ACSQH, Australian Commission on Safety and Quality in Healthcare.
The Pattern of Abbreviation Use in Prescriptions Current Drug Safety, 2014, Vol. 9, No. 1 5

Table 2a. Reference List of Error-Prone Abbreviations (Table 2a) contd…...

Error-Prone Abbreviation Intended Meaning

Error-Prone Abbreviation Intended Meaning N or n Night

µg Microgram Occ or oc Eye ointment

Mcg Microgram Mist Mixture

BID or bid Twice a day Trailing zero -

AD, AS, AU Right ear, left ear, each ear Lack of leading zero -

OD, OS, OU Right eye, left eye, each eye Large doses without
100,000 units 1,000,000 units
properly placed commas
OW Once week
APAP acetaminophen
p/f Per fortnight
ARA A vidarabine
BT Bedtime
AZT zidovudine (Retrovir)
cc Cubic centimeters
CPZ compazine (prochlorperazine)
D/C Discharge or discontinue
DPT Demerol-Phenergan-Thorazine
e/ E Eye
Diluted tincture of opium,
gtt or gutte Drops DTO
or deodorized tincture of opium
IJ Injection HCl hydrochloric acid or hydrochloride
IN Intranasal HCT hydrocortisone
IT Intrathecal HCTZ hydrochlorothiazide
HS or hs Half-strength at bedtime, hours of sleep MgSO4 magnesium sulfate
IU International units MTX methotrexate
o.d. or OD Once daily PCA procainamide
OJ Orange juice PTU propylthiouracil
Per os By mouth, orally T3 Tylenol with codeine No. 3
Pulv Powder TAC triamcinolone
q.d. or QD Every day TNK TNKase
q.h Every hour ZnSO4 zinc sulfate
qhs Nightly at bedtime “Nitro” drip nitroglycerin infusion
qn Nightly or at bedtime “Norflox” norfloxacin
q.o.d. or QOD Every other day “IV Vanc” intravenous vancomycin
q1d Daily x3d For three days
q6PM, etc. Every evening at 6 PM > and < Greater than and less than
SC, SQ, sub q Subcutaneous / (slash mark) Separates two doses or indicates “per”
SL Sublingual @ At
ss Sliding scale (insulin) or ½ (apothecary) & And
SSRI Sliding scale regular + Plus or and
SSI Sliding scale insulin ° Hour
i/d, i/D One daily .or. zero, null sign
TIW or tiw Three times a week MS Morphine sulphate or magnesium sulphate
TID Three times a day MSO4 Morphine sulphate
U or u Unit 6/24 Every six hours
UD As directed (“ut dictum”) 1/7 For one a day
Ung Ointment ½ Half
M or m Morning 10 6
One million
6 Current Drug Safety, 2014, Vol. 9, No. 1 Samaranayake et al.

Table 2b. Standard Abbreviation List of the Hospital (Table 2b) contd…..
Authority of Hong Kong Approved Abbreviations for Drug Names
Full Name Abbreviation
Approved Abbreviations for Drug Names
Full Name Abbreviation Riboflavine Vit. B2
Sodium Bicarbonate NaHCO3
Acetomenaphthone Vit K4
Sodium chloride NaCl
Adenosine Triphosphate ATP
Teniposide VM-26
Adrenocorticotrophic Hormone ACTH
Thiamine Vit. B1
Adsorbed Diphtheria & Tetanus Vaccine DT
Thyrotrophin-releasing hormone TRH
Adsorbed Diphtheria, Tetanus & Pertussis Vaccine DTP
Thyroxine T4
Alpha Tocopheryl Acetate Vit. E
Liothyronine Sodium T3
Alpha Tocopheryl Nicotinate Vit. E
Zinc Oxide ZnO
Ascorbic Acid Vit. C
Balance Salt Solution BSS
Bacillus Calmette Guerin Vaccine BCG Vaccine
Dihydrocodeine Tartrate DF118
Calcium Carbonate CaCO3
Expectorant Stimulant MES
Calcium Chloride CaCl2
Hydrocortisone 1% & Clioquinol 3% H1V3
Carmustine BCNU
Multivitamin MV
Cisplatin CDDP
Vitamin B Complex Vit.B Co
Cyanocobalamin Vit. B12
Cytarabine Ara-C Approved Abbreviations for Route of Administration

Desmopressin DDAVP Full Name Abbreviation

Ergocalciferol, Calciferol Vit. D2 Intradermal I.D.

Erythropoietin EPO Intramuscular I.M.
Etoposide VP-16 Intravenous I.V.
Ferrous Sulphate FeSO4 Intraperitoneal I.P.
Filgrastim G-CSF Nasogastric N.G.
Fluorouracil 5-FU Per oral P.O.
Glyceryl Trinitrate GTN, TNG Per rectum P.R.
Hepatitis B Immune Globulin HBIG Per vagina P.V.
Isoniazid INAH Subcutaneous S.C.
Lomustine CCNU Sublingual S.L.
Magnesium chloride MgCl2
Magnesium Sulphate MgSO4 and one question was added. The questionnaire was
translated to Sinhalese language and the validity of the
Measles/Mumps/Rubella Vaccine MMR Vaccine
translation was assessed by a back translation method.
Mercaptopurine 6-MP
Ethical approval was obtained from the Ethics Review
Methotrexate MTX Committees of the Faculty of Medical Sciences, University
Molgramostim GM-CSF of Sri Jayewardenepura, Sri Lanka and the Colombo South
Teaching Hospital, Sri Lanka. Informed consent was
Phenoxymethylpencillin Pencillin V obtained from all participants before the survey.
Phytomenadione Vit. Kl
Potassium Chloride KCl Statistical Analysis
Potassium Iodide KI Data were analysed using SPSS 19.0 (IBM Corporation,
Armonk, NY). The number of drug items prescribed in each
Potassium Permanganate KMnO4
phase was used as the denominator for calculating
Propylthiouracil PTU percentages in the prescription review study and the number
Prostaglandin E2 PGE2
of pharmacists that responded to the survey was used as the
denominator when analysing survey results.
Pyridoxine Hydrochloride Vit. B6
The Pattern of Abbreviation Use in Prescriptions Current Drug Safety, 2014, Vol. 9, No. 1 7

RESULTS lists. 2/9 error-prone abbreviations were cautioned by 3 of

the lists and 4/9 were cautioned by 2 lists.
989 prescriptions that included 3370 drug items were
reviewed in the study hospital. The mean (standard All the pharmacists (N=19) who were invited, responded
deviation) number of abbreviations per prescription was 5.9 to the survey. Their demographic characteristics are shown
(3.5). According to the reference list, the types of error-prone in Table 5. Most pharmacists were 31–40 years of age and
abbreviations used by prescribers and the rate of usage are most were females. The minimum qualification required to
shown in Table 3. ‘µg’ (microgram), ‘d’ (days/daily) and ‘n’ be recruited as a pharmacist in a Sri Lankan hospital is a
(night) were the most commonly used error-prone Certificate of Proficiency awarded by the Ceylon Medical
abbreviations in the study hospital. Among the 103 types of College Council of Sri Lanka.
abbreviations observed, 71 were unapproved (Table 3). All pharmacists believed that using abbreviations will
Multiple abbreviations were used to indicate a single drug always (5.3%) or sometimes (94.7%) lead to medication
item/ instruction in 7 instances (Table 4). The abbreviation errors. The reasons they believed that may lead to
‘d’ was used to denote ‘daily’ as well as ‘days’. medication errors are shown in Fig. (1). Other reasons
Table 3. Error-Prone and Some Other Unapproved include, the ambiguity due to incomplete prescriptions,
Abbreviations Used in the Study Hospital prescriptions not conforming to a uniform standard, different
styles of hand-writing used by prescribers, and the use of
Abbreviation Percentage of Usage*
non-standard abbreviations formed by different prescribers
which would especially be unfamiliar to junior pharmacists.
Error-Prone Abbreviations All pharmacists strongly agreed or agreed that confusing or
misleading abbreviations should not be used in prescriptions
d (days/daily) 23.5 and all acceptable abbreviations should be standardised.
µg (microgram) 17.4
n (night) 15.8 DISCUSSION
m (morning) 4.4 In this study we aimed to study the use of error-prone
abbreviations and other inappropriately used abbreviations in
@ sign 4.9
prescriptions. Approximately 69 error-prone abbreviations
u (units) 1.9 are used per every 100 drug items prescribed. Similar to our
cc (cubic centimeter) 0.2 study, Dooley et al., also observed 76.9 error-prone
abbreviations per every 100 patients and 8.4 error-prone
OD (once a day) 0.2 abbreviations per every 100 prescriptions [6]. Further,
mcg (microgram) 0.1 abbreviations are used rather inconsistently in prescriptions.
A large number abbreviations used are not standard or
Some Frequently Used Unapproved Abbreviations acceptable. Some drug items or instructions are identified by
several abbreviations, and some abbreviations have more
pcm/PCM (paracetamol) 5.2
than one intended meaning. An example of an abbreviation
LA (local application) 2.2 that had more than one intended meaning from this study is
MS (methyl salicylate) 1.9 the abbreviation ‘d’ which was used to mean ‘days’ as well
as ‘daily’. It would not be surprising if a pharmacist
o (oral) 1.5 interpreted ‘2d’ as ‘two tablets daily’ when it was meant to
syr/sy (syrup) 1.3 read ‘one tablet for 2 days’. In such a case, the consequences
to the patient, especially if the drug has a narrow therapeutic
BCo (vitamin B complex) 0.8
index would be significant.
DFS (diclofenac sodium) 0.7
The use of inappropriate abbreviations may not only
HCT (hydorchlorothizide) 0.7 affect health care professionals but may cause problems to
ISMN (isosorbide mononitrate) 0.7 patients, particularly older patients when managing their
numerous drugs [16]. Although technical abbreviations are
tsp/ TSP (teaspoon) 0.6 not expected to be interpreted by patients, simple
EOD (every other day) 0.5 abbreviations such as the letter ‘l’ used for ‘liter’ could
easily be misinterpreted as number one. Similarly, patients
FA (folic acid) 0.5
may misread number ‘1’ as number ‘7’, letter ‘o’ as number
α or 1α (1α colecalciferol) 0.3 ‘0’, and letter ‘z’ as number ‘2’ [17]. Therefore we
ASP (Aspirin) 0.3
emphasise the importance of eliminating error-prone
abbreviations and standardising the use of acceptable
MSLA (methyl salicylate local application) 0.3 abbreviations as a vital necessity in hospitals that use hand-
ISDN (isosorbide mononitrate) 0.2 written prescriptions.
*The number of drug items reviewed (N= 3370) was used as the denominator. Error-prone abbreviations were used in prescriptions of
the study hospital but most were not identified in some of the
Only 1/9 error-prone abbreviations used in the study error-prone abbreviation lists that already exist in other
hospital was cautioned by all four error-prone abbreviation countries [3-5, 15]. In fact, most error-prone abbreviations
8 Current Drug Safety, 2014, Vol. 9, No. 1 Samaranayake et al.

Table 4. Multiple Abbreviations Used to Denote the Same Drug Name/Instruction

Drug Name or Instruction Abbreviation 1 %* Abbreviation 2 %* Abbreviation 3 %*

Diclofenac sodium DF 0.1 DFS 0.7 Diclo Na 0.1

Folic acid FA 0.5 F.acid 0.1 - -
Glyceryle trinitrate GTN 0.7 TNT 0.1 - -
Paracetamol P.mol 0.03 PCM 5.2 Par 0.03
As needed PRN 0.1 SOS 1.2 - -
Thyroxine T4 0.03 T 0.1 Thy 0.03
Microgram µg 5.1 mcg 0.03 - -
Nocte n 4.7 Nt 0.1 Noc 0.03
Methyle salicylate MS 1.9 MSLA 0.3 - -
Vesper (evening) v 0.1 ves 0.1 - -
*The number of drug items observed (N=3370) was used as the denominator.

Table 5. Demographic Characteristics of Survey Participants sulphate’ or ‘magnesium sulphate’ in the ISMP and JCAHO
in the Study Hospital lists, but is used to mean ‘methyle salisylate’ in the study
hospital. Hence it is clear that an error-prone abbreviation
Characteristic N = 18† list intended for one setting is not always applicable to
another. It would therefore be more prudent to develop an in-
Age Groups, % house list of error-prone abbreviations that target
inappropriate practices of the respective setting.
21 – 30 11.1
Attitudes of pharmacists are an important source to
31 – 40 33.3
determine difficulties associated with illegible prescriptions
41 – 50 55.5 and ambiguous abbreviations. Therefore it is very important
Sex, %
to involve practicing pharmacists in the development of
error-prone abbreviation lists. Further, awareness programs
Men 27.8 should aim at informing prescribers of the difficulties created
Women 72.2 on their account.
Higher Education Level , % * There are some limitations to this study. Firstly the study
involved only one major government hospital in Sri Lanka
Certificate of Proficiency only 88.9 and hence may not reflect the overall pattern of using error-
Diploma in Pharmacy 22.2 prone and other unapproved abbreviations in the country.
However, this need not affect our conclusion as similar
Degree in other discipline 16.7
findings were observed in other studies [6] and our previous
Postgraduate 5.6 unpublished audits in Hong Kong. Secondly, our
Years of Experience as a Pharmacist, %
prescription sample did not include in-ward prescriptions but
as in-ward doctors participate in clinics, their pattern of
< 1 years 5.6 using abbreviations was also reflected in our findings. The
1– 5 years 16.7 inappropriate abbreviations encountered in this study and the
error-prone abbreviations specified by ‘Do Not Use’ lists are
6 – 10 years 22.2 in English or Latin. Abbreviations may differ depending on
>10 years 55.6 the language and country and hence the findings of this study
*Percentages do not add up to 100% as some pharmacists had more than one may only apply to countries where prescriptions are written
qualification. in English.
†Demographic data was missing in one participant.
The number of pharmacists who were attached to the
outdoor pharmacy was limited. Therefore the sample of
used in the study setting, were not included in the JCAHO participants who were surveyed was small but included all
and HAHK lists. Furthermore, many other potentially the pharmacists in the out-patient pharmacy. A 100%
dangerous unapproved abbreviations used in prescriptions response rate was achieved, but the responses may have been
have not even been identified as error-prone. An example is biased. The pharmacists were well aware of the aims and
the use of ‘O’ to mean ‘oral’ which could also be read as a objectives of the study which may have influenced their
‘zero’. Pharmacists also pointed out that using ‘O’ is too attitudes on using unapproved abbreviations. Therefore, it
vague as they sometimes could not differentiate between the must be borne in mind that the attitudes of this small group
tablet and capsule forms. Sometimes the intended meaning of pharmacists may not be generalisable. Care should be
of an abbreviation could vary by country. For example, ‘MS’
is an error-prone abbreviation specified for ‘morphine
 The Pattern of Abbreviation Use in Prescriptions Current Drug Safety, 2014, Vol. 9, No. 1 9

Fig. (1). Reasons why abbreviations may lead to medication errors. The percentages do not add up to 100% because each pharmacist may
have suggested more than one reason.

taken when interpreting the survey results until supported by [3] Institute of Safe Medication Practices. ISMP's list of error-prone
more larger and representative studies. abbreviations, symbols and dose designations. 2004 [Updated 2013
January 1: Cited 2013 July 1]; Available from:
We conclude that error-prone abbreviations are used in http://www.ismp.org/tools/errorproneabbreviations.pdf.
prescriptions and more than half the abbreviations used in [4] The Joint Commission. Facts about the official ‘Do Not Use’ list. 2004
[Updated 2013 June 18: Cited 2013 July 1]; Available from:
prescriptions are unapproved. Some drugs or instructions are http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf.
identified by multiple abbreviations, while some abbreviations [5] Australian Commission on Safety and Quality in Healthcare. National
have several interpretations. Unfortunately, the pattern of using terminology, abbreviations and symbols to be used in the prescribing
unapproved abbreviations by prescribers is inconsistent and and administering of medicines in Australian hospitals. 2006 [Updated
2006 October; Cited 2013 July 1]; Available from:
changes by hospital or country. Pharmacists who are involved in http://www.safetyandquality.gov.au/wp-
interpreting prescriptions agree that this erratic use of content/uploads/2012/01/18146.pdf.
abbreviations may lead to medication errors. Therefore hospitals [6] Dooley MJ, Wiseman M, Gu G. Prevalence of error-prone
that use hand-written prescriptions should inform prescribers of abbreviations used in medication prescribing for hospitalised patients:
this danger and develop in-house error-prone abbreviations list Multi-hospital evaluation. Intern Med J 2012; 42(3): e19-22.
[7] Miasso AI, Oliveira RCD, Silva AEBDC, et al. Prescription errors in
for their guidance. Further, the use of acceptable abbreviations Brazilian hospitals: a multi-centre exploratory survey.
should be standardised by introducing a standard abbreviations Cad Saude Publica 2009; 25: 313-20.
%
list. [8] Myers JS, Gojraty S, Yang W, Linsky A, Airan-Javia S, Polomano RC.
A randomized-controlled trial of computerized alerts to reduce
unapproved medication abbreviation use. J Am Med Inform Assoc
CONFLICT OF INTEREST 2011; 18(1): 17-23.
[9] Whyte M. Computerised versus handwritten records. Pediatr Nurs
The authors confirm that this article content has no conflict 2005; 17(7): 15-8.
of interest. [10] Kuhn IF. Abbreviations and acronyms in healthcare: When shorter isn't
sweeter. Pediatr Nurs 2007; 33(5): 392-8.
[11] Kushlan JA. Use and abuse of abbreviations in technical
ACKNOWLEDGEMENTS communication. J Child Neurol 1995; 10(1): 1-3.
[12] Dunn EB, Wolfe JJ. Let go of Latin!. Vet Hum Toxicol 2001; 43(4):
BMY Cheung received support from the Faculty Research 235-6.
Fund, Li Ka Shing Faculty of Medicine, University of Hong [13] Sheppard JE, Weidner LCE, Zakai S, Fountain-Polley S, Williams J.
Kong. N.R. Samaranayake holds a University Postgraduate Ambiguous abbreviations: an audit of abbreviations in paediatric note
Fellowship and a Postgraduate Scholarship from the University keeping. Arch Dis Child 2008; 93(3): 204-6.
[14] NR Samaranayake, STD Cheung, W Chui, Cheung. B. Reducing the
of Hong Kong. N.R. Samaranayake also holds the Wong Ching use of inappropriate abbreviations in prescriptions. Hong Kong Med J
Yee Medical Scholarship for 2012. 2012; 18(Supplement 1): 45.
[15] Medication Incident Reporting Program Bulletine. Update of “Do Not
Use” list. Hong Kong Hospital Authority 2010 [cited 2010 August];
PATIENT CONSENT Available from: http://www.ha.org.hk/haho/ho/hesd/MIRP25e.pdf.
Declared none. [16] D Fialová, G Onder. Medication errors in elderly people: contributing
factors and future perspectives. Br J Clin Pharmacol 2009; 67(6): 641-5.
[17] Institute of Safe Medication Practices. Medical errors from misreading
REFERENCES letters and numbers. 2010 [Updated 2010 March; Cited 7 December
2013]; Available from:
[1] von Eschenbach AC. Eliminating error-prone notations in medical http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?s
communications. Expert Opin Drug Saf 2007; 6(3): 233-4. how=96#7
[2] Benjamin DM. Reducing medication errors and increasing patient
safety: Case studies in Clinical Pharmacology. J Clin Pharmacol 2003;
43: 768.

Received: October 17, 2013 Revised: December 11, 2013 Accepted: December 13, 2013

DISCLAIMER: The above article has been published in Epub (ahead of print) on the basis of the materials provided by the author. The Editorial Department
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