ISMP Updates Tool for Error Prone Abbreviations, Symbols, and Dose Designations

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By Matt Phillion

The Institute for Safe Medication Practices (ISMP) has released an update to its recommendations for conventions used to communicate medical information that can be frequently misinterpreted.

The terms included in the 2024 List of Error-Prone Abbreviations, Symbols, and Dose Designations are gathered through reports to ISMP’s voluntary error reporting program and have been involved in harmful or potentially harmful medication errors.

These abbreviations, symbols, and dose designations should not be used in verbal, handwritten, or electronic communications, ISMP notes, such as:

  • Internal communications
  • Verbal, handwritten, or electronic prescriptions
  • Handwritten or computer-generated medication labels
  • Drug storage bin labels
  • Medication administration records
  • Screens associated with pharmacy and prescriber computer order entry systems
  • Automated dispensing cabinets
  • Smart infusion pumps
  • Other medication-related technologies

The list is intended to encourage organizations to examine their own “do not use” lists, and the updated list is included on The Joint Commission’s own list to enable easier reference.

The 2024 changes include:

  • When a dose is measured in nanograms, doing away with the abbreviation “nanog” and rather spelling out the word completely.
  • No longer using “NAS” as an abbreviation for intranasal medications, spelling out the full word instead.
  • Using QHS or qhs to indicate when a medication is intended to be used nightly at bedtime, rather than writing out “nightly” or “HS.”
  • No longer reducing font-sized fractions when indicating a half-tablet. Instead, use text and avoid using fractions or decimals.
  • No longer using “per” when a slash mark is needed to separate doses. Use “and” instead.

The list is updated periodically, or when a needed change is trending, or a concern arises in reports to the program.

Keeping pace with emerging trends

Updating the list offers an opportunity to remove confusion or concern among commonly used terms, explains Ann Shastay, MSN RN, AOCN, senior manager of ISMP Publications.

“Nanograms is a good example. Previously maybe it was OK to use ‘nanog’ as an abbreviation, but looking back, it’s better to spell it out to prevent confusion,” she says.

In other cases, such as the intranasal medication abbreviation, confusion arises from duplication of use of the tern.

“While ‘NAS’ has been used in the past, one of our team members noted it’s an abbreviation for something else in pediatrics,” says Shastay.

Occasionally, an update can be a little surprising.

“In the final stages of revising the document, we were looking at the half-tablet indication where we might use a fraction, but we saw confusion about whether this meant one half or two tablets. We actually received an error report from a consumer who had taken two tablets instead of a half tablet,” Shastay explains. “So we’re saying you should write it out to be clearer.”

In a space where things change rapidly and consistently, staying on top of the list is the real challenge, Shastay says.

“We have to think about all the types of communication in the healthcare setting,” she says. “Back in the day, everything was written down, so initially this list came from that—where the handwritten orders got confused because everyone has different handwriting.”

Technology has added complexity to abbreviations.

“Where we once had only written and verbal, we use computers for everything now. People though the electronic record would get rid of all these errors, and we wouldn’t have these communications issues, but even if you use the right abbreviation, you contend with font sizes, character limits, things in the system that make the entry look different,” says Shastay. “It’s about taking all of those things into account.”

A community effort

All of this can’t happen without healthcare practitioners and consumers reporting errors when they encounter them, Shastay says.

“By reporting, we can analyze them and see if there’s a problem with how the order is communicated,” she says. “That’s something we stay on top of all the time: reviewing those error reports and asking questions about how it was communicated.”

There’s no shortage of data coming in. Reports arrive every day through three error reporting programs. The first is the general, national medication errors reporting program, which is primarily information provided by physicians, nurses, pharmacists, and other providers.

“Anyone in the field has access to that,” says Shastay.

There is also a consumer medication error program, allowing not just the patients themselves to report in but also caregivers of those patients—all the more important with how frequently patients are cared for at home.

Lastly, there is the vaccine error reporting program, which naturally specifically addresses vaccines.

It’s not just humans who benefit from these programs. ISMP even learns of error reports about pet medication filled at retail pharmacies which allows for the opportunity to improve communication with those medication orders as well.

Improving Do Not Use lists is a joint effort.

“Systematically, organizations need to have a process where they review their list of Do Not Use abbreviations, and if they’re Joint Commission-accredited, they have that Do Not Use list as well,” says Shastay. “They should be regularly reviewing and revising those lists, looking at not just our list but others as well. Many organizations have their own internal data. It’s about knowing what’s happening in your organization, so you know what to focus on.”

The reason The Joint Commission works with ISMP in maintaining their list is a matter of staying informed and helping with enforcement. The ISMP list is advisory, and thus including an accrediting body offers a way to hold organizations accountable for maintaining an up to date and accurate list of Do Not Use abbreviations.

(The Joint Commission’s Do Not Use list can be found under Information Management Standard 02.02.01.)

“We communicate with organizations like The Joint Commission, the FDA, and the CDC as well as various practitioner organizations” to help get the word out about the most up to date recommendations, Shastay says.

Don’t silo your efforts

Of course, not everything on the updated list applies to all organizations. If they are not applying certain drugs on the list, it may not be an area requiring focus, but it’s important to periodically review internal data and policies to see if medications have added, or been removed from, those internal lists.

Who leads the charge will vary based on the resources and assets of each individual organization. Some organizations have a dedicated mediation safety officer to take charge of this process, but this may also be led by their pharmacy or a therapeutics committee, or teams of doctors, nurses, and pharmacists.

“It shouldn’t be siloed,” advises Shastay. “It’s not just about the pharmacy or nurses – anyone who touches medication should be involved.”

Organizations can stay up to speed on the latest news about error-prone abbreviations, symbols, and dose designations through ISMP’s website and publications.

“We’re constantly updating our newsletter publications and staying on top of the latest topics and getting the word out about what’s coming in through our error reports,” says Shastay.

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.