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NCC MERP 15 Year Anniversary Report

National Coordinating Council for Medication Error Reporting and Prevention

Council Recommendations PrintPrint

Recommendations to Enhance Accuracy of Prescription Writing

Personnel to whom this applies: Prescribers; Nursing or Pharmacy staff (who transcribe verbal prescription orders or rewrite transfer or admission orders when entering or leaving a health care facility); Health care administrators/managers.

Technology plays an important role in the delivery of healthcare. Utilize technology, as appropriate, but evaluate its effectiveness on an ongoing basis. While technology can reduce medication errors and enhance patient safety, it also has the potential to cause new types of unintentional errors.

The Council recommends:

  1. ...all prescription documents be legible. Verbal orders should be minimized. (See the Council's Recommendations to Reduce Medication Errors Associated with Verbal Medication Orders and Prescriptions)
  2. ...prescription orders include a brief notation of purpose (e.g., for cough), unless considered inappropriate by the prescriber. Notation of purpose can help further assure that the proper medication is dispensed and creates an extra safety check in the process of prescribing and dispensing a medication. The Council does recognize, however, that certain medications and disease states may warrant maintaining confidentiality.
  3. ...all prescription orders be written in the metric system except for therapies that use standard units such as insulin, vitamins, etc. Units should be spelled out rather than writing "U." The change to the use of the metric system from the archaic apothecary and avoirdupois systems will help avoid misinterpretations of these abbreviations and symbols, and miscalculations when converting to metric, which is used in product labeling and package inserts.
  4. ...prescribers include age and, when appropriate, weight of the patient on the prescription or medication order. The most common errors in dosage result in pediatric and geriatric populations. The age (and weight) of a patient can help dispensing health care professionals in their double check of the appropriate drug and dose.
  5. ...medication orders include drug name, exact metric weight or concentration, and dosage form. Strength should be expressed in metric amounts and concentration should be specified. Each order for a medication should be complete. The pharmacist should check with the prescriber if any information is missing or questionable.
  6. ...a leading zero always precede a decimal expression of less than one. A terminal or trailing zero should never be used after a decimal. Ten-fold errors in drug strength and dosage have occurred with decimals due to the use of a trailing zero or the absence of a leading zero.
  7. ...prescribers avoid the use of abbreviations including those for drug names (e.g., MOM, HCTZ) and Latin directions for use. The abbreviations in the chart below are found to be particularly dangerous because they have been consistently misunderstood and therefore, should never be used. The Council reviewed the uses for many abbreviations and determined that any attempt at standardization of abbreviations would not adequately address the problems of illegibility and misuse.

    Abbreviation Intended meaning Common Error
    U Units Mistaken as a zero or a four (4) resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written.
    µg Micrograms Mistaken for "mg" (milligrams) resulting in an overdose.
    Q.D. Latin abbreviation for every day The period after the "Q" has sometimes been mistaken for an " I, " and the drug has been given "QID" (four times daily) rather than daily.
    Q.O.D. Latin abbreviation for every other day Misinterpreted as "QD" (daily) or "QID" (four times daily). If the "O" is poorly written, it looks like a period or "I."
    SC or SQ Subcutaneous Mistaken as "SL" (sublingual) when poorly written.
    T I W Three times a week Misinterpreted as "three times a day" or "twice a week."
    D/C Discharge; also discontinue Patient's medications have been prematurely discontinued when D/C, (intended to mean "discharge") was misinterpreted as "discontinue," because it was followed by a list of drugs.
    HS Half strength Misinterpreted as the Latin abbreviation "HS" (hour of sleep).
    cc Cubic centimeters Mistaken as "U" (units) when poorly written.
    AU, AS, AD Latin abbreviation for both ears; left ear; right ear Misinterpreted as the Latin abbreviation "OU" (both eyes); "OS" (left eye); "OD" (right eye)
    IU International Unit Mistaken as IV (intravenous) or 10(ten)
    MS, MSO4, MgSO4 Confused for one another Can mean morphine sulfate or magnesium sulfate
  8. ...prescribers avoid vague instructions such as "Take as directed" or "Take/Use as needed" as the sole direction for use. Specific directions to the patient are useful to help reinforce proper medication use, particularly if therapy is to be interrupted for a time. Clear directions are a necessity for the dispenser to: (1) check the proper dose for the patient; and, (2) enable effective patient counseling.

In summary, the Council recommends:

Don't Wait . . . Automate!
When In Doubt, Write It Out!
When In Doubt, Check It Out!
Lead, Don't Trail

Adopted: Sept. 4, 1996
Revised: June 2, 2005

Actions/Decisions are those of the Council as a whole and may not reflect the views/positions of individual member organizations.

© 2014 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. *Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied. This copyright statement will change to the new year after the 1st of every year.