Facts about the Official “Do Not Use” List

Facts about the Official “Do Not Use” List In 2001, The Joint Commission issued a Sentinel Event Alert on the subject of medical abbreviations, and just one year later, its Board of Commissioners approved a National Patient Safety Goal requiring accredited organizations to develop and implement a list of abbreviations not to use. In 2004, The Joint Commission created its “do not use” list of abbreviations (see below) as part of the requirements for meeting that goal. In 2010, NPSG.02.02.01 was integrated into the Information Management standards as elements of performance 2 and 3 under IM.02.02.01. Currently, this requirement does not apply to preprogrammed health information technology systems (for example, electronic medical records or CPOE systems), but this application remains under consideration for the future. Organizations contemplating introduction or upgrade of such systems should strive to eliminate the use of dangerous abbreviations, acronyms, symbols, and dose designations from the software. Official “Do Not Use” List Do Not Use U, u (unit) IU (International Unit) Q.D., QD, q.d., qd (daily) Potential Problem Mistaken for “0” (zero), the number “4” (four) or “cc” Mistaken for IV (intravenous) or the number 10 (ten) Mistaken for each other Q.O.D., QOD, q.o.d, qod (every other day) Trailing zero (X.0 mg)* Lack of leading zero (.X mg) MS Period after the Q mistaken for "I" and the "O" mistaken for "I Decimal point is missed MSO4 and MgSO4 Confused for one another 1 Can mean morphine sulfate or magnesium sulfate 1 Use Instead Write "unit" Write "International Unit" Write "daily" Write "every other day" Write X mg Write 0.X mg Write "morphine sulfate" Write "magnesium sulfate" Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms. *Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation. The National Summit on Medical Abbreviations Participants at the November 2004 National Summit on Medical Abbreviations supported the “do not use” list. Summit conclusions were posted on the Joint Commission website for public comment. During the four-week comment period, the Joint Commission received 5,227 responses, including 15,485 comments. More than 80 percent of the respondents supported the creation and adoption of a “ do not use” list. This special one-day Summit brought together representatives of more than 70 professional societies and associations and special interest groups to discuss medical errors related to the misuse and misinterpretation of abbreviations, acronyms, and symbols. The objective of the Summit was to reach consensus on the scope and implications of this serious and complex problem and to find reasonable solutions using all of the evidence at hand and in the most dispassionate way possible. The National Summit on Medical Abbreviations was hosted by The Joint Commission with its coconveners American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, American Society of Health-System Pharmacists, Institute for Safe Medication Practices, and United States Pharmacopeia. Approximately 50 professional societies and associations and selected interest groups participated in the Summit representing every perspective.