Medication errors abbreviations

USP received a medication error report involving the products Neumega (oprel-vekin) and Proleukin (aldesleukin). Oprelvekin, a recombinant human interleukin-11 product used to stimulate platelet production in selected patients undergoing chemotherapy, is sometimes abbreviated as IL-11. Aldesleukin, a recombinant human interleukin-2 derivative indicated in designated patient populations for the treatment of metastatic renal-cell carcinoma, is sometimes abbreviated as IL-2. 

Abbreviations and dose expressions cause medication errors. The handwritten or printed u intended to abbreviate unit can easily be misinterpreted as a zero, causing a 10-fold overdose. Decimal points can be difficult to read on prescriptions or orders, causing a 10-fold dose error. Decimals less than 1 should always be preceded by a zero (use 0.2, not. 2) and a whole number should not be followed by a zero (use 2, not 2.0). The Institute for Safe Medicafion Practices (ISMP) has additional recommendations on abbreviations and dose expressions (Table 16.6). ... 

JCAHO Sentinel Event Alert No. 23 Medication errors related to potentially dangerous abbreviations, September 2001. Available at www.jcaho.org, accessed August 5, 2002. 

FIGURE A—1 The prescription. The prescription must be carefully prepared to identify the patient and the medication to be dispensed, as well as the manner in which the drug is to be administered. Accuracy and legibility are essential. Use of abbreviations, particularly Latin, is discouraged, as it leads to dispensing errors. Inclusion of the purpose of the medication in the subscription (e.g., control of blood pressure") can prevent errors in dispensing. For example, the use of losartan for the treatment of hypertension may require 100 mg/day (1.4 mg/kg per day), whereas treat-... 

The Joint Commission for Accreditation of Hospitals Organization (JCAHO) has recommended that these abbreviations not be used to decrease the chance of errors. However, some hospitals and providers continue to use them when writing medications orders. 

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