Introduction

Physicians and other prescribers enter medication and treatment orders on a computer or the patient’s medical record on a page usually designated “Physician’s Order Sheet” or “Doctor’s Order Sheet.” Several abbreviations are used to write medication orders, labels, and records.

The medication orders are sent to the pharmacy. The trend has been for the pharmacy to transfer the orders to their computerized forms. In most hospitals, medications are charged to the patient and delivered to the patient’s area by the pharmacy in unit-dose (single-serving) packages labeled in metric system measurements. The medications may be stocked in a locked cabinet or in drawers of a locked medication cart until needed and restocked periodically by the pharmacy, usually every 24 hours.

The nurse must check the complete written order against the label on the medication supplied. If there is any discrepancy, the physician or pharmacist, whoever is more appropriate for the situation, must be contacted. If the amount of the dose is ordered based on the patient’s weight or the amount of drug on hand is not identical to the amount ordered, a calculation may be needed. Usually, such calculations can be performed mentally, but sometimes written mathematics or a calculator is needed.

There is potential for error in each step of the written process, including the order, the medication administration record, the supplied medication and its label, and the preparation and administration. The nurse who administers the medication is legally responsible for the medications given even if the order was wrong or the medication and/or dose supplied by the pharmacy was in error. The nurse provides the final protection for patients in the medication chain.

This chapter focuses on reading and interpreting medication dose orders, labels, and abbreviations within the context of patients’ safety. Abbreviations and measurements learned in earlier chapters are incorporated.

ESSENTIAL Vocabulary

Adverse Drug Event (ADE) A medication-related event that causes harm to a patient. Can be caused by improper label, prescription, dispensing, administration, among other factors. Refer to http://www.psqh.com/novdec06/librarian.html.

Drug Form The composition of a drug: liquid or solid; tablet, capsule, or suppository, etc.

Drug Route The body location where the drug will be administered, e.g., mouth, nasogastric (nose to stomach), vein, muscle, subcutaneous tissue, rectum, or vagina.

FDA Food and Drug Administration, the federal agency responsible for approving tested drugs for consumer use in the United States.

Generic Drug Official name used for a drug by all companies that produce it. For example, there are many brands and trade names for acetaminophen, the generic name for Tylenol. Acetaminophen is the official name. Tylenol is a brand name. Generic drugs are identical or bioequivalent to brand-name drugs in dosage form, safety, strength, route of administration, quality, performance, and intended use.

High-Alert Medications High-alert medications are medications that have been identified by ISMP as those that can cause significant harm to patients when used in error. The icon is a visual reminder to help you become familiar with some of these medications. Refer to the ISMP’s list of high-alert medications in Appendix B as you work through the text and prepare patient care plans.

MAR Medication Administration Record, the official record of all medications ordered for and received by each patient during an inpatient visit. It is maintained by nurses. Each page may reflect one or more hospital days.

ISMP Institute for Safe Medication Practices.

NF National Formulary, the official resource for the contents of generic drugs. NF is occasionally seen on medication labels.

NKA No known allergies.

NKDA No known drug allergies.

OTC Drug Drug sold and purchased “over the counter” in drugstores, grocery stores, and health food stores without a prescription. Some were formerly required to be dispensed only by prescription and have been released from that requirement by the FDA.

Patent Official permission from the U.S. Patent Trade Office to market a drug exclusively for 20 years from the time of application. The patent period compensates the first company to market a drug for the costs of drug research and development. After the patent period expires, other manufacturers may apply to sell the generic form of the drug and must meet the same standards as the original company.

Sentinel Event An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Includes among other, severe adverse drug events (ADE). Refer to www.jointcommission.org/SentinelEvents.

TJC The Joint Commission.

Trade Name Name assigned to a product by its manufacturer. The symbol ® written as a superscript after a trade name indicates that the manufacturer has officially registered that name for the product with the U.S. Patent Trade Office.

24-Hour Clock System for telling time that begins with 0001 (1 minute after midnight) and ends with 2400 (midnight). Also known as the international clock or military time. The 24-hour clock system is used internationally and has been adopted in the United States by many agencies to avoid potential confusion caused by duplication of AM and PM hours (a 12-hour clock).

Unit Dose Single serving size of a drug (e.g., 250 mg per tablet, 250 mg per 5 mL).

Unit-Dose Packaging Unit-dose packaging of single servings functions as a safety net. It helps limit the amount of overdose and/or waste that might occur. Refer to Figure 4-3.

USP United States Pharmacopoeia, the official drug reference that lists all FDA-approved generic drugs. USP can be seen next to the generic name on some drug labels.

Usual Dose Manufacturer’s recommendation for the average dose strength (concentration) that usually achieves the desired therapeutic effect for the target population (e.g., “for adults with fever, 1-2 tablets every 4-6 hours, not to exceed 6 tablets in 24 hours”). Based on clinical trials, the usual dose is often specified by the patient’s weight and occasionally by body surface area or age.

Q: Ask Yourself

A: My Answer

Medication Storage and Security

Medications for institutional use are stored in locked cabinets, carts, and drawers (Figure 4-1).

Bar codes are increasingly used to reduce medication errors. The pharmacy enters the patients’ drug information, records, and medication orders into a computer. Each dose is bar-coded in the pharmacy. The nurse uses a hand-held scanner to scan the drug and the patient’s wrist bracelet (Figure 4-2). The computer checks that it is the right medication for the right patient. Unit-dose medications supplied by the pharmacy also reduce medication errors.

Controlled (scheduled) drugs such as narcotics, opiates, and some non-narcotic drugs such as tranquilizers and anti-anxiety agents, have special locked storage, dispensing, disposal, and documentation requirements because of potential risk for abuse. They are placed in schedules by the Federal Drug Administration (DEA). Schedule C I (Control I) refers to drugs at the highest risk for abuse, such as crack cocaine and heroin, Schedules C II through C V drugs, which are prescribed for medical purposes, are labeled as such, with Schedule C V having least potential for abuse. Note the C II classification for morphine on the label below.

Refer to Essential Vocabulary in this chapter and Appendix B for a list of high-alert medications.

Medication Forms and Packaging

Medications are supplied in a variety of solid and liquid forms, including granules, tablets, capsules, suppositories, and various liquid preparations. The physician’s order must specify the form of the medication. A single medication may be prepared in several forms and marketed and packaged in several single and/or multidose sizes. Multidose sizes are convenient for pharmacy and home use (Figure 4-3). At most clinical facilities, the pharmacy packages smaller single-serving-size amounts from the multidose containers to reduce medication errors (Figure 4-4).

Since medications are supplied in a variety of forms to meet patients’ needs, it is important to select the form that matches the physician’s order. This is done by matching the order to the medication label. The orders for medication forms are abbreviated. There is a trend to reduce and or eliminate abbreviations in medical records.

Solid Drug Forms

Table 4-1 lists solid medication abbreviations, terms, and forms. Since the nurse must be able to interpret the abbreviations and terms, the contents of Table 4-1 should be memorized.

Q: Ask Yourself

A: My Answer

Liquid Drug Forms

Liquid drug forms are packaged in small prefilled unit-dose-serving containers and larger stock bottles, such as the containers seen for multidose home prescriptions. The liquids are supplied and administered through a variety of routes to the patient in an amount of milliliters.

Liquid drug forms are administered using specially calibrated equipment: cups; teaspoons; needles attached to tubing; syringes with needles; needle-less syringes; droppers for the mouth, eye, or ear; or tubes for the stomach and intestine. See Figures 4-5 and 4-6 for some examples of oral liquid medication equipment.

Doses of oral liquid medications such as milk of magnesia (MOM) can be supplied in small single-dose packages or larger multidose bottles. As stated in Chapter 3, 5 mL and 15 mL are the equivalents of 1 calibrated teaspoon and 1 calibrated tablespoon, respectively. The manufacturer attempts to provide the usual drug dose for the target population within those two measurements because they are reasonable volumes to swallow.

Abbreviations appear in most patients’ orders and medication records. They may be handwritten or printed. Memorize the abbreviations in Table 4-2.

Q: Ask Yourself

A: My Answer

Medication Routes

Medication routes can be divided into two types:

Nonparenteral routes through which medications are delivered include the following:

Several abbreviations are used in medication orders to describe specific nonparenteral routes of administration (Table 4-3). Some of these abbreviations are derived from Latin and Greek. The abbreviations must be learned even though the trend is to write more of them out in English to avoid misinterpretation.

Q: Ask Yourself

A: My Answer

Q: Ask Yourself

A: My Answer

The routes listed in Table 4-4 are for parenteral, or injectable, medications. Parenteral medications are administered under the skin into soft tissue, muscle, vein, or spinal cord. Memorize the abbreviations and terms in the table.

Q: Ask Yourself

A: My Answer

Frequency and Times of Medication

Table 4-5 lists abbreviations for terms that denote the frequency and times of medication administration. Memorize the abbreviations in the table.

TABLE 4-5

Medication Frequency and Time

Abbreviation or Term	Meaning
ā or a	Before
	After
	With (e.g., with meals)
	Without
ac	Before meals
pc	After meals
ad lib	Give as desired; pertains to fluids and activity, not to medication
bid	Two times a day
tid	Three times a day
qid	Four times a day
on call	Give the medication when the x-ray department or the operating room (OR) calls for the patient
prn	As needed
q	Each, every
qh	Every hour
q2h	Every 2 hours
q4h	Every 4 hours
q6h	Every 6 hours
q8h	Every 8 hours
q12h	Every 12 hours
qhs	Every night at bedtime
stat	Immediately and only one dose

Q: Ask Yourself

A: My Answer

Q: Ask Yourself

1. What is the error on the TJC list, Table 4-6 that can occur with abbreviations beginning with a “Q”?

TABLE 4-6

The Joint Commission Official “Do Not Use” List

Do Not Use	Potential Problem	Use Instead
U (unit)	Mistaken for “0” (zero), the number “4” (four) or “cc”	Write “unit”
IU (International Unit)	Mistaken for IV (intravenous) or the number 10 (ten)	Write “International Unit”
Q.D., QD, q.d., qd (daily)	Mistaken for each other	Write “daily”
Q.O.D., QOD, q.o.d., qod (every other day)	Period after the Q mistaken for “I” and the “O” mistaken for “I”	Write “every other day”
Trailing zero (X.0 mg)†	Decimal point is missed	Write X mg
Lack of leading zero (.X mg)		Write 0.X mg
MS	Can mean morphine sulfate or magnesium sulfate	Write “morphine sulfate”
MSO4 and MgSO4	Confused for one another	Write “magnesium sulfate”

	Additional Abbreviations, Acronyms and Symbols (For possible future inclusion in the Official “Do Not Use” List)
Do Not Use	Potential Problem	Use Instead
> (greater than)	Misinterpreted as the number “7” (seven) or the letter “L”	Write “greater than”
< (less than)	Confused for one another	Write “less than”
Abbreviations for drug names	Misinterpreted due to similar abbreviations for multiple drugs	Write drug names in full
Apothecary units	Unfamiliar to many practitioners	Use metric units
	Confused with metric units
@	Mistaken for the number “2” (two)	Write “at”
cc	Mistaken for U (units) when poorly written	Write “mL” or “ml” or “milliliters” (“mL” is preferred)
μg	Mistaken for mg (milligrams) resulting in one thousand-fold overdose	Write “mcg” or “micrograms”

^*Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.

Copyright The Joint Commission, 2010. Reprinted with permission.

^†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.

    _________________________________________________________________________

2. What is the error that can occur with the abbreviation for International Unit?

    _________________________________________________________________________

3. To which kind of specific orders and documentation must the TJC official “Do Not Use” list apply?

    _________________________________________________________________________

4. What does the ISMP List, Table 4-7, recommend about writing of drug names and doses? Numerical doses and unit of measure?

TABLE 4-7

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations

Dose Designations and Other Information	Intended Meaning	Misinterpretation	Correction
Drug name and dose run together (especially problematic for drug names that end in “I” such as Inderal40 mg; Tegretol300 mg)	Inderal 40 mg	Mistaken as Inderal 140 mg	Place adequate space between the drug name, dose, and unit of measure
	Tegretol 300 mg	Mistaken as Tegretol 1300 mg
Numerical dose and unit of measure run together (e.g., 10mg, 100mL)	10 mg	The “m” is sometimes mistaken as a zero or two zeros, risking a 10- to 100-fold overdose	Place adequate space between the dose and unit of measure
	100 mL
Abbreviations such as mg. or mL.with a period following the abbreviation	mg	The period is unnecessary and could be mistaken as the number 1 if written poorly	Use mg, mL, etc.without a terminal period
	mL
Large doses without properly placed commas (e.g., 100000 units; 1000000 units)	100,000 units	100000 has been mistaken as 10,000 or 1,000,000; 1000000 has been mistaken as 100,000	Use commas for dosing units at or above 1,000, or use words such as 100 “thousand” or 1 “million” to improve readability
	1,000,000 units
Drug Name Abbreviations	Intended Meaning	Misinterpretation	Correction
ARA A	vidarabine	Mistaken as cytarabine (ARA C)	Use complete drug name
AZT	zidovudine (Retrovir)	Mistaken as azathioprine or aztreonam	Use complete drug name
CPZ	Compazine (prochlorperazine)	Mistaken as chlorpromazine	Use complete drug name
DPT	Demerol-Phenergan- Thorazine	Mistaken as diphtheria- pertussis-tetanus (vaccine)	Use complete drug name
DTO	Diluted tincture of opium, or deodorized tincture of opium (Paregoric)	Mistaken as tincture of opium	Use complete drug name
HCI	hydrochloric acid or hydrochloride	Mistaken as potassium chloride (The “H” is misinterpreted as “K”)	Use complete drug name unless expressed as a salt of a drug
HCT	hydrocortisone	Mistaken as hydrochlorothiazide	Use complete drug name
HCTZ	hydrochlorothiazide	Mistaken as hydrocortisone (seen as HCT250 mg)	Use complete drug name
MgSO4*	magnesium sulfate	Mistaken as morphine sulfate	Use complete drug name
MS, MSO4*	morphine sulfate	Mistaken as magnesium sulfate	Use complete drug name
MTX	methotrexate	Mistaken as mitoxantrone	Use complete drug name
PCA	procainamide	Mistaken as patient controlled analgesia	Use complete drug name
PTU	propylthiouracil	Mistaken as mercaptopurine	Use complete drug name
T3	Tylenol with codeine No.3	Mistaken as liothyronine	Use complete drug name
TAC	triamcinolone	Mistaken as tetracaine, Adrenalin, cocaine	Use complete drug name
TNK	TNKase	Mistaken as “TPA”	Use complete drug name
ZnSO4	zinc sulfate	Mistaken as morphine sulfate	Use complete drug name

Stemmed Drug Names	Intended Meaning	Misinterpretation	Correction
“Nitro” drip	nitroglycerin infusion	Mistaken as sodium nitroprus-side infusion	Use complete drug name
“Norflox”	norfloxacin	Mistaken as Norflex	Use complete drug name
“IV Vanc”	intravenous vancomycin	Mistaken as Invanz	Use complete drug name
Symbols	Intended Meaning	Misinterpretation	Correction
	Dram	Symbol for dram mistaken as “3”	Use the metric system
	Minim	Symbol for minim mistaken as “mL”	Use the metric system
x3d	For three days	Mistaken as “3 doses”	Use “for three days”
and	Greater than and less than	Mistaken as opposite of intended; mistakenly use incorrect symbol; “ 10” mistaken as “40”	Use “greater than” or “less than”
/(slash mark)	Separates two doses or indicates “per”	Mistaken as the number 1 (e.g., “25 units/10 units” misread as “25 units and 110” units)	Use “per” rather than a slash mark to separate doses
@	At	Mistaken as “2”	Use “at”
&	And	Mistaken as “2”	Use “and”
+	Plus or and	Mistaken as “4”	Use “and”
°	Hour	Mistaken as a zero (e.g., q2º seen as q 20)	Use “hr, ”“h,” or “hour”

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