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FDA, ISMP Launch Campaign to Promote Safer Medication Orders

By News Staff

In an effort to cut down on the thousands of deaths each year that are caused by medication errors, the FDA and Institute for Safe Medication Practices, or ISMP, have launched a joint initiative aimed at educating health professionals to avoid using unclear medical abbreviations and notations.

Photo of public service announcement
"Some abbreviations, symbols and dose designations are frequently misinterpreted and lead to mistakes that result in patient harm," said FDA Acting Commissioner Andrew von Eschenbach, M.D., in a June 14 news release announcing the effort. "This joint campaign will promote safe practices among those who communicate medical information to help avoid serious and even potentially fatal consequences of medication errors."

According to the Institute of Medicine, medication mistakes account for more than 7,000 patient deaths annually and can occur at any stage of the medication usage system and across all health care settings. This campaign will focus specifically on abbreviations and notations used in various medical communications, from written drug orders created by physicians to hospital medication administration records, and from computerized order entry screens used in pharmacies to drug packaging materials developed by manufacturers.

Examples of error-prone abbreviations and notations include
  • U -- can be mistaken for zero or the numeral 4; write as "unit,"
  • IU -- can be mistaken for "IV" or the numeral 10; write as "international unit,"
  • Trailing zero -- decimal point may be missed; five milligrams should be written as "5 mg" rather than as "5.0 mg" (Note: leading zeroes should be used before decimal points; e.g., write "0.5 mg" instead of ".5 mg"), and
  • MSO4 and MgSO4 -- can be confused with one another; write as "morphine sulfate" and "magnesium sulfate," respectively.
The ISMP has generated a list of commonly used and potentially problematic abbreviations, symbols and dose designations. The list is available online, along with various other campaign materials, such as
  • a brochure aimed at health professionals, the pharmaceutical industry and medical communications professionals;
  • a print public service ad;
  • educational posters;
  • an online toolkit that includes a PowerPoint presentation; and
  • an FDA patient safety video with written transcript.

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