Medication Order Writing & the
“Do Not Use” Abbreviations
 To enhance understanding of the linkages between medication
safety and communication.
 To ensure that all healthcare professional and associated staff
are familiar with the “DO NOT USE: Dangerous Abbreviations
and Symbols, Dose Designations” Materials from the Manitoba
Institute for Patient Safety.
 To review Manitoba cases of communication breakdowns in
medication order writing related to dangerous, abbreviations and
symbols.
 To understand personal responsibilities related to safe
medication practices.
The reduction and mitigation of unsafe
acts within the healthcare system, as
well as through the use of best practices
shown to lead to optimal patient
outcomes
Davies JM, Hébert P, Hoffman C. The Canadian Patient
Safety Dictionary. Ottawa: Royal College of
Physicians and Surgeons of Canada; 2003:12.

Medication errors - 106,000
deaths a year average of 300
deaths per day, every day.

Deaths from all major airline
crashes in the U.S. average
less than 300 annually

Media/Public attention on
airline crash vs. med error
deaths which are like an
airline crash, but every day.

7.5% of patients
experienced 1 or more
adverse events

36.9% of these patients
experienced a highly
preventable adverse
event

9,250 to 23,750 deaths
from adverse events
could have been
prevented
CMAJ 2004
1.
2.
3.
4.
5.
Human factors
COMMUNICATION
Name confusion
Labeling
Packaging
Retrospective analysis of mortalities associated
with medication errors.
Am J Health-Syst Pharm – Vol 58 Oct 1, 2001
1.
2.
3.
4.
5.
Human factors
COMMUNICATION
Name confusion
Labeling
Packaging
Retrospective analysis of mortalities associated
with medication errors.
Am J Health-Syst Pharm – Vol 58 Oct 1, 2001
Verbal Communication Failure

A nurse in a busy emergency
department received a verbal order
for digoxin and wrote the order as it
was ‘heard’.

The nurse intended to give the higher
end of the dosing range as the
patient was very unwell.

Fortunately, an error was avoided
when it was identified through further
communication with other health care
providers that the intent of the
prescriber was Digoxin 0.125 mg po
daily.
WRHA Example
“Digoxin .1 to 5 mg po daily”
Written Communication Failure

Coumadin 1mg or 10mg? Patient
received 10mg when 1mg was
intended.

Risperidone 1.0mg or 10mg? The
intent was 1mg.

Intended dose of “0.4mg” of
vincristine but was interpreted as
4mg from medication order.
Should be written as 0.4mg.
WRHA and FDA Examples

Text
◦ Text 2

Text
◦ Text 2



MK is a 67 year old male with a 10 year history of type 2 diabetes
He has recently been started on insulin and has been reasonably
well controlled
He seen in the ER and diagnosed with pneumonia. He is started on
IV levofloxacin and transferred to a medical ward where the
following order is written:

Entered in the pharmacy system with a frequency of once daily

Nursing Medication Administration Record reflects a frequency of
QID (four times daily).
80% of errors occurred when the prescription was written but 20%
occurred afterwards (ex. transcription)
Joint Commission Journal of Quality and Safety 2007
An assessment of MK’s blood sugar shows a fasting
blood sugar of 27
 The physician on rounds suggests an additional dose of
regular insulin and writes the following order

The prescription for 6 units of regular insulin was
misinterpreted as “60”
 60 units of regular insulin was given
 MK became hypoglycemic and unresponsive but made
a full recover after the administration of IV glucose
 Recommendation: Write out “units” to avoid confusion


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Patient Safety is in YOUR Hand!
Posters to address specific
abbreviations
DO NOT USE: Dangerous
Abbreviations, Symbols and Dose
Designations
Adapted from Institute for Safe
Medications Practices (ISMP)
listing
Endorsed by Colleges, WRHA
and is in use in some form in all
RHAs in Manitoba
Posters are Copyright of the Winnipeg Region Health Authority
Posters are Copyright of the Winnipeg Region Health Authority

Public awareness and
expectation that all
reasonable measures are
taken to ensure safety

Professional
Responsibilities

Medical-Legal issues

Accreditation Canada Required Organizational
Practice 2009


The organization has identified and implemented a list of
abbreviations, symbols, and dose designations that are not to be
used in the organization.
Order Writing Standards

Most RHAs have already adopted Order Writing Standards that
address the issue of abbreviations and other order writing
practices
“When anyone asks me how I can best describe my
experience in nearly forty years at sea, I merely say,
uneventful. Of course there have been winter gales, and
storms and fog and the like. But in all my experience, I
have never been in any accident ... or any sort worth
speaking about. I have seen but one vessel in distress in
all my years at sea. I never saw a wreck and never have
been wrecked nor was I ever in any predicament that
threatened to end in disaster of any sort."
Edward J. Smith, 1907
Captain, RMS Titanic, 1912

Set a personal example

Consider standard orders,
care maps and guidelines

Medication Labels and
Software

Advertising

Journal Articles

Trade Journals






Avoid writing ambiguous orders with Do Not Use abbreviations
in written orders
Safety First – seek clarification of any order that is unclear or
ambiguous
Work with computer software vendors to make changes in
electronic order entry programs.
Consider Computerized Physician Order Entry (CPOE) Systems
that avoid both handwriting challenges and the use of unclear
abbreviations (ex. CancerCare MB)
Ensure all staff have access to the MIPS “Do Not Use”
Documents
Include MIPS “Do Not Use” information in training of healthcare
employees and students
Team Approach
Management
Support Staff
Nurses
Physicians
Pharmacists
Medication
Safety
 Educational
Outreach/Awareness
 Local Champions
 Mandatory Education
 Audit and Feedback
 Challenges
Habits of order writing are deeply ingrained
Perceived lack of importance
…and/or Stick
 “Enforcement
outdoes education at eliminating
unsafe abbreviations”
 AJHP
2004; 61: 1314-1315.
 Anecdotal discussion with 3 major healthcare facilities in
the United States
 All conducted extensive educational outreach
 None showed any marked improvement in abbreviation
use
 Two of the facilities implemented strategies that lead to
improvements in order writing
…and/or Stick
 Strategy
#1
 All medication orders with unacceptable abbreviations
were considered to be invalid and required that the
prescribers rewrite the orders
 Strategy
#2
 Developed a physician-owned process. They had to
manage it, and they had to enforce it
MIPS

http://www.mbips.ca/wp/initiatives/patient-safety-is-in-your-hand/
FDA

http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/default.htm
ISMP

http://www.ismp.org/tools/abbreviations
Health Canada

http://www.hc-sc.gc.ca/dhp-mps/medeff/advers-react-neg/index-eng.php

Post Test – Review Your Knowledge of “Do Not
Use” Abbreviations

http://www.mbips.ca/wp/hidden-link/exam-test-page/

Accreditation form will be emailed upon completion of post test

Pharmacists: Accredited by MPhA #30196M

Nurses: Participation in this self-directed learning
activity may fulfill the requirements of the College of
Registered Nurses of Manitoba Continuing Competence
Program.

Please retain post test as record of self directed learning