Abbreviation	Meaning	Example of Usage on a Doctor’s Order Sheet
ADE	adverse drug event	[ADEs are common and costly]
ASA	acetylsalicylic acid or aspirin	ASA 81 mg PO q day
BCOC or LOC	bowel care of choice or laxative of choice	BCOC as per patient requestLOC as per patient request
BS	bedside	NTG 0.4 mg subling prn, keep @ BS
cc(same as “mL” and may not be allowed in some facilities, as it may be confused with “U” or “u” if poorly written)	cubic centimeters	MOM 30cc po prn
G, gm, or g	gram	cefadroxil 1 g IVPB q6h
gr	grain	chloral hydrate gr XV PO hs prn
HA or H/A	headache	Tylenol 650 mg prn H/A
IM	intramuscular	vitamin B₁₂ 1000 mcg deep IM tomorrow
IV	intravenous	D/C IV if infiltrates
IVP	intravenous push	theophylline 5 mg/kg IVP now
IVPB	intravenous or IV piggyback	cephalothin 0.5 g IVPB q8h
KCl	potassium chloride	Add 40 mEq KCl to each IV
L	liter	1 L 5% D/W to run @ 125 mL/hr
mcg	microgram	vitamin B₁₂ 1000 mcg IM
mEq	milliequivalent	Give 20 mEq KCl per open heart protocol
mg	milligram	ciprofloxacin 250 mg PO q12°
mL or ml	milliliter (same as cubic centimeter)	1000 mL 5% D/W @ KO rate
noc	night	Ambien 10 mg po q noc
NTG	nitroglycerin	NTG 0.4 mg subling for heart pain prn
OTC	over-the-counter	The patient was not taking any OTC medications
oz	ounce	Add 8 oz of juice to Metamucil packet
PCA	patient-controlled analgesia	PCA morphine sulfate 2 mg q15 min
PCN	penicillin	PCN 250 mg PO q 6 hr
PO or po	per os (by mouth)	lorazepam 2 mg PO tid
Pr or R	per rectum	bisacodyl supp 10 mg pr now
prn	pro re nata (as needed)	Maalox 30 mL prn GI discomfort
sq, or sub-q	subcutaneous	heparin 5000 unit sub-q daily
subling, sl	sublingual (under tongue)	nitroglycerin tab sl prn anginal pain
supp	suppository	acetaminophen supp prn for temp ↑ 100°^(R)
syr	syrup	ipecac syr 15 mL now
tinct or tr	tincture	Apply tinct of benzoin around operative site before applying tape

See Table 10-1 for a list of incorrect and correct abbreviations, as approved by The Joint Commission (TJC). Some hospitals have additional abbreviations to avoid using, such as those listed in Table 13-1.

TABLE 13-1

A Hospital’s List of Additional Abbreviations to Avoid

Abbreviation	Potential Problem	Preferred Term
IM	Because of poor writing, often misinterpreted as “IV,” causing the medication to be given via the wrong route	Write out “intramuscular”
D/C	Patient’s medications may be prematurely discontinued when D/C means “discharge” and is followed by a list of medications	Write out “discontinue”
HS	May be misinterpreted as “hour of sleep” when written as meaning “half-strength”	Write out “half-strength”
IVP	When written to mean “intravenous push,” may be mistaken for “intravenous piggyback” (IVPB)	Write out “intravenous push”
S/C or S/Q	When poorly written, often mistaken for “SL” (sublingual)	Write out “subcutaneous”
Slash mark: /	Misunderstood as the number “1” rather than the intended meaning “per”	Write out “per”

HIGH PRIORITY

The use of electronic medical records (EMRs) and e-prescribing greatly reduces confusion and medication errors involving medical abbreviations.

EXERCISE 2

Write the meaning of each abbreviation listed.

Computer Physician Order Entry and Clinical Decision Support System

Adverse drug events (ADEs) result in more than 770,000 injuries and deaths each year and cost up to $5.6 million per hospital, depending on size. Illegible doctors’ handwriting and transcription errors are responsible for as much as 61% of the medication errors. Medication errors may involve the wrong drug or the incorrect dose. Errors can go undetected unless there is an adverse event. A simple mistake such as putting the decimal point in the wrong place can have serious consequences because a patient’s dose could be 10 times the recommended amount. Drugs with similar names are also a common cause of error, such as quinine (used to treat malaria) and quinidine (used to normalize the heartbeat in people with certain heart rhythm disorders) or Zyrtec (used to treat allergies) and Zyprexa (used to treat schizophrenia and bipolar disorder). Other ADEs occur as a result of administration mistakes, including the wrong frequency or time, or the incorrect route, or medication not administered at all.

U.S. hospitals that have switched to computer physician order entry (CPOE) systems have experienced a 66% drop in prescription errors according to a new review of studies. When CPOE is used, the doctor enters orders directly into the patient’s electronic medical record (EMR) via computer, and the orders are automatically sent to the pharmacy, reducing the risk of errors in interpreting doctors’ handwriting. E-prescribing is the process of sending a medication order or prescription from the prescriber’s computer to the pharmacy computer. The clinical decision support system (CDSS) provides the doctor with prompts that warn against the possibility of drug interaction, allergy, or overdose at the point of order entry.

Health Unit Coordinator Role Regarding Medication Orders with and without an Electronic Medical Record with Computer Physician Order Entry

Health unit coordinators (HUCs) working in hospitals that have implemented an EMR system with CPOE no longer have the responsibility of interpreting doctors’ handwritten medication orders. It is, however, beneficial that the HUC recognize medication orders. The HUC will still have some responsibilities involving medications, such as ordering stock medications for the nursing unit and printing required computerized medication pamphlets prior to a patient’s discharge. The HUC may also be required to include some types of medications on requisitions (such as anticonvulsants for a neurodiagnostics test). The goal is for all hospitals to have EMR with CPOE in 2014, but as of 2012 most hospitals do not have electronic prescription systems (stand-alone or as part of an EMR program) in use. Electronic prescription systems are costly and difficult to integrate into the sometimes chaotic hospital structure. The HUC is still transcribing medication orders in many hospitals. Transcription of medication orders will vary among hospitals and may involve writing ordered medications on the patient’s paper medication administration record (MAR) or entering medications into the patient’s computerized MAR. (Review transcription of medication orders in Chapter 9.)

HIGH PRIORITY

Until all hospitals have implemented the electronic medical record (EMR) with computer physician order entry (CPOE), medication orders will be included in this text.

Administration of Medication

Medication Carts

Medications are usually stored in a medicine cart that is prepared by the pharmacy and sent to the units daily. Use of medication carts reduces the risk of mislabeled medications, ensuring that regulations of the Food and Drug Administration (FDA) are met. Two types of medication carts are used. One is a unit dose medicine cart that contains “unit doses” in separate drawers or bins specifically labeled for each patient as ordered by the doctor(s). The pharmacist fills these orders by reading the computerized orders written by the physician, or by reading a hard or faxed copy of the physician’s orders. The unit dose medication cart can be wheeled to the patient’s bedside for administration of the medication (Fig. 13-1). The second type is a computerized medication cart such as a Pyxis that requires the nurse to enter a confidential user identification (ID) and password to unlock the cart. The nurse always verifies the name of the medication, the dose, and the patient’s name before removing the medication. The computerized medication carts remain in the medication room and are not taken from room to room. Some hospitals lock intravenous (IV) solutions in a storage cabinet that is located next to the computerized medication cart, and both can be opened only when a nurse enters an assigned code (Fig. 13-2). All medications and/or IV solutions that are removed can be tracked on the computer by the code entered at the time of removal. When a computerized medication cart is used, the pharmacist enters the instructions for each patient’s medications into the cart (usually for a 24-hour period).

Figure 13-1 Medication cart. (From Lilley LL, Aucker RS: *Pharmacology and the nursing process,* ed 3, St Louis, 2001, Mosby.)

Figure 13-2 Computerized medication cart, including intravenous solutions.

A registered nurse or a licensed practical nurse who is caring for a number of specific patients will administer medications to those patients. Alternatively, a registered nurse or a licensed practical nurse may be assigned to serve as the “med nurse” and will administer medications to all patients on the nursing unit.

Medication Stock Supply

Hospitals store a supply of medications on nursing units, often in the computerized medication cart. This supply is often called the medication stock supply, and it includes many over-the–counter (OTC) drugs such as aspirin, acetaminophen, mineral oil, and milk of magnesia. When floor stock medicines are ordered from the pharmacy, they are charged to the unit budget.

The Medication Administration Record

The medication administration record (MAR), as described in Chapter 8, is a form on which nursing personnel record all medications given to the patient; it is a permanent part of the patient’s chart (electronic or paper). Nurses use the MAR as a reference while preparing medications for administration (if medication carts are not used) and while administering medications. The nurse signs the MAR electronically (when the EMR is used) or manually (when paper charts are used) at the bottom of the form at the end of each shift to indicate that the patient received the medications as charted or did not receive any medications if none were ordered. Currently, three methods of completing MARs are used.

If the EMR is implemented in the facility, the medications are entered on the MAR when the doctor writes the order, and the registered or licensed practical nurse enters the time at which the medications are administered into each patient’s computerized MAR. The electronic MAR is a permanent part of the patient’s EMR.

If the EMR is not being used, the pharmacy prepares a printed medication record for each patient, which is sent to the nursing unit each morning. The registered nurse or the HUC adds to the MAR any new medications ordered, along with any changes to medication orders made during the day. The pharmacist, after having received the faxed physician orders, makes those changes, and the printed MAR sent the next morning reflects those changes. When the patient is discharged, the printed MARs become a permanent part of the patient’s chart.

A handwritten MAR is used when CPOE or the printed MAR initiated by the pharmacy has not been implemented. Transcribing of medication orders may require the HUC to write the order on the MAR. In some hospitals, nurses are responsible for writing their assigned patients’ medication orders on the MAR. Accuracy in copying the medication order from the physician’s order sheet onto the MAR is absolutely essential. The HUC initiates the record on the patient’s admission. The record varies in the number of days (3 to 10 days) that medications may be entered. When the last date of the dated period on the MAR has been reached, a new record with new dates is prepared, and all medications still in use are copied onto the new form. Handwritten MARs are also a permanent part of the patient’s chart. The MAR is a legal document, so entries are required to be written in ink (usually black) (Fig. 13-3). To discontinue medications on the MAR, indicate “DC” on the correct day and time, and draw a line through the days the medication will not be given. A yellow or pink highlight is usually drawn over the medication entry that is discontinued (see Fig. 13-3, A).