Error-Prone Drug Name Abbreviations

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.
Drug Name Abbreviations	Intended Meaning	Misinterpretation	Correction
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
Stemmed Drug Names	Intended Meaning	Misinterpretation	Correction
“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
NOTES
*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.
REFERENCES
Source: Institute for Safe Medication Practices. Error-Prone Abbreviations, Symbols, and Dose Designations. 2015. Available at: http://www.ismp.org/Tools/ errorproneabbreviations.pdf. (Rev. 5/2018)

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