Prescription Writing Do's and Don'ts

The Joint Commission has established a national Patient Safety Goal that specifies that certain abbreviations must appear on an accredited organization's do-not-use list. The following are these abbreviations and dose designations that have caused errors and have been reported to the Institute for Safe Medication Practices as being frequently misinterpreted:

Abbreviation Intended Meaning Misinterpretation Correction
IU International unit Mistaken as IV (intravenous) or 10 (ten) Use "units"
q.d. or QD Every day Mistaken as q.i.d. (four times daily), especially if the "q" or the tail of the "q" is understood as an "I" Use "daily"
q.o.d. or QOD Every other day Mistaken as q.d. or q.i.d. if the "o" is poorly written Use "every other day"
U or u Unit Mistaken as the number 0 or 4, causing a 10-fold overdose or greater (e.g. 4U seen as "40" or 4u seems as"44); mistaken as "cc" so dose given in volume instead of units (e.g. , 4U seen as 4cc) Use "unit"
Dose Designations Intended Meaning Misinterpretation Correction
Trailing zero after decimal point (e.g. 1.0 mg) 1 mg. Mistaken as 10 mg if the decimal point is not seen Do not use trailing zeros for doses expressed in whole numbers
"Naked" decimal point (e.g. .5 mg) 0.5 mg Mistaken as 5 mg if the decimal point is not seen Use zero before a decimal point when the dose is less than a whole unit
Drug Name Abbreviation Intended Meaning Misinterpretation Correction
MgS04 Magnesium sulfate Mistaken as morphine sulfate Use complete drug name
MS, MS04 Morphine sulfate Mistaken as magnesium sulfate Use complete drug name