Do Not Use Medical Abbreviations: Do This Instead

Do Not Use medical abbreviations are the shorthand forms that The Joint Commission bans from orders and medication-related documentation because they’re easy to misread. The official list is short. It covers “U,” “IU,” “QD,” “QOD,” “MS,” “MSO4,” and “MgSO4,” along with trailing zeros and missing leading zeros, and each one has a plain replacement.

The Institute for Safe Medication Practices (ISMP) keeps a longer list of error-prone abbreviations, symbols, and dose designations, and many hospitals fold part or all of it into their own policies.

If you write orders, give medications, or set documentation policy, below you’ll find both lists with what to write instead, why these forms still lead to medication errors, where they slip into electronic records, and how one health system cut its use of prohibited abbreviations by more than 80%.

What is the Joint Commission Do Not Use list?

The Joint Commission’s Do Not Use list is a short set of abbreviations, symbols, and dose designations that accredited organizations can’t use in orders and medication-related documentation. It grew out of a 2001 Sentinel Event Alert on medical abbreviations and a 2002 National Patient Safety Goal that asked organizations to develop their own lists. The Joint Commission published the official list in 2004 to set a minimum and prevent serious medication errors, according to its fact sheet on the Do Not Use list.

Today, the requirement sits in the Information Management chapter of the accreditation manual, under standard IM.02.02.01. The list applies to handwritten orders, free-text entries in an electronic record, and pre-printed forms.

It’s a floor. Organizations can add their own prohibited abbreviations, and many do. Banning every abbreviation isn’t realistic, though. “Not allowing the use of any abbreviations would be an exceedingly difficult edict to introduce and enforce,” writes Neil M. Davis, PharmD, MS, FASHP, in a piece for ISMP. That’s why most organizations pair the Do Not Use list with a list of abbreviations staff can use. (Here’s how teams build an approved abbreviation list.)

The official Do Not Use list of medical abbreviations

Here’s the full Joint Commission list, with the problem each abbreviation causes and what to write instead.

Do not use	Potential problem	Write instead
U, u (unit)	Mistaken for 0 (zero), the number 4, or “cc”	unit
IU (International Unit)	Mistaken for IV (intravenous) or the number 10	International Unit
Q.D., QD, q.d., qd (daily)Q.O.D., QOD, q.o.d., qod (every other day)	Mistaken for each other. The period after the Q can be read as an “I,” and the “O” can be read as an “I.”	dailyevery other day
Trailing zero (X.0 mg)Missing leading zero (.X mg)	The decimal point is missed	X mg0.X mg
MS	Can mean morphine sulfate or magnesium sulfate	morphine sulfatemagnesium sulfate
MSO4 and MgSO4	Confused for one another	morphine sulfatemagnesium sulfate

There’s one exception. A trailing zero can appear where it shows a level of precision, such as a lab result, the size of a lesion on an imaging report, or a catheter or tube size. It can’t appear in a medication order or other medication documentation.

Dangerous abbreviations beyond the Do Not Use list

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations goes further. It’s built from reports to the ISMP National Medication Errors Reporting Program, and every entry has been misinterpreted in a way that caused or could have caused harm. ISMP says these forms shouldn’t appear in any medical communication, spoken, handwritten, or electronic, including order-entry screens, automated dispensing cabinets, and smart infusion pumps.

The list is long, so here are a handful of the entries people look up most, grouped the way ISMP groups them.

Route and frequency abbreviations

Subcutaneous should never be written as “SC,” “SQ,” or “sub q.” ISMP recommends “SUBQ” (all capitals, no spaces or periods) or the full word “subcutaneous.”

Abbreviation	Intended meaning	Misread as	Write instead
SC, SQ, sub q	Subcutaneous	SL (sublingual), “5 every,” or “every”	SUBQ or subcutaneous
IN	Intranasal	IM or IV	intranasal
OD, od	Once daily	Right eye	daily
TIW, tiw	Three times a week	Three times a day or twice a week	3 times weekly
AU, AS, AD	Each ear, left ear, right ear	OU, OS, OD (each eye, left eye, right eye)	each ear, left ear, right ear
D/C	Discharge or discontinue	The opposite meaning	discharge, or discontinue (stop)

Dose designations and symbols

Dose designations cause trouble because a single misread character changes the amount. These are the most common.

Abbreviation or symbol	Intended meaning	Misread as	Write instead
µg	Microgram	mg (milligram)	mcg
cc	Cubic centimeters	u (units)	mL
x1	Give once	For one day	for 1 dose
@, &	At, and	The number 2	at, and
+	Plus or and	The number 4	plus, and
/ (slash)	Separates two doses	The number 1	and
> and <	More than, less than	The opposite symbol, or “<10” read as 40	more than, less than

Drug name abbreviations

ISMP’s 2024 list includes 24 rows of drug name abbreviations and recommends avoiding them altogether. Its only exception covers some multi-ingredient products, like vitamins, when an electronic drug name field runs out of space. Drug name abbreviations should never be used for high-alert medications. A few examples:

Abbreviation	Intended drug	Mistaken for
APAP	Acetaminophen	Not recognized
AZT	Zidovudine	Azithromycin, azathioprine, or aztreonam
HCTZ	Hydrochlorothiazide	Hydrocortisone
MTX	Methotrexate	Mitoxantrone
PCA	Procainamide	Patient-controlled analgesia
ZnSO4	Zinc sulfate	Morphine sulfate

For each one, write the complete drug name.

Why prohibited abbreviations still cause fatal medication errors

Most of these abbreviations are only a letter or a dot away from something else. That’s what makes the errors so large.

A “U” that looks like a zero turns 4 units of insulin into 40, a 10-fold overdose. A missed decimal point does the same thing in the other direction, so 1.0 mg becomes 10 mg, and a missed decimal in .5 mg turns it into 5 mg. ISMP notes that “qd” has been read as “qid,” which quadruples a daily dose.

Look-alike pairs add a second kind of risk. “MS” can mean morphine sulfate or magnesium sulfate, two drugs with very different effects. ISMP has also seen “ZnSO4” read as morphine sulfate.

The evidence goes back years. A 2012 study in the Canadian Journal of Hospital Pharmacy describes the use of abbreviations as “an underlying cause of serious, even fatal medication errors.” It also cites a review by the Pennsylvania Patient Safety Authority, which found that 56% of 103 critical incidents involved dangerous abbreviations and dose expressions.

Abbreviations also create risk outside the pharmacy. Forensic psychiatrist Thomas G. Gutheil, MD, points out how many people read a medical record. The treatment team, covering and on-call clinicians, utilization and quality reviewers, and insurers all read it, and sometimes a plaintiff’s attorney and a jury do too. A lay reader can’t understand clinical reasoning hidden in shorthand. “Clinical judgment is itself the polar opposite of negligence, one of the critical elements of malpractice,” Gutheil writes.

Where dangerous abbreviations show up in EHRs

Electronic health records solved the handwriting problem, but not the abbreviation problem. Free-text fields, order comments, typed progress notes, and transcribed verbal orders still accept anything a clinician types. Habits travel, too. “Even when physicians intentionally try to avoid abbreviations, they still manage to slip in,” says Dr. Jared Ross of Emergency Medical Services, Education, & Consulting.

A few EHR features make it easier for a prohibited abbreviation to stick around:

• Copy-forward. A copied note carries every abbreviation in it into the next day’s documentation. The Joint Commission’s Quick Safety advisory on copy and paste recommends clear policies on what can be copied, visible markers for copied text, and regular audits.
• Personal macros and templates. A template saved years ago keeps inserting the old form until someone updates it, and individual copies rarely get updated together.
• Autocomplete and picklists. These help when all options on the list are approved. When the list itself contains an error-prone form, autocomplete surfaces it to every user. Third-party text expansion software can offer real-time autocomplete too, and the same rule applies.

Health systems fight back in a few ways. Clinical decision support can flag a prohibited abbreviation in real time as it’s entered, and many systems set up EHR alerts for error-prone forms. Standardized order sets keep medication instructions clear and unambiguous, and order-entry screens can display and print only the full term, though some of these changes take EHR development time. EHR smart phrases and macros can insert the written-out form so nobody has to remember it.

Natural language processing tools can help eliminate ambiguous language in clinical documentation, and other tools expand abbreviations automatically. One caution applies to all of them. An ambiguous abbreviation like “MS” can’t be expanded safely without context, because the tool would have to guess. The safer design gives each shortcut one meaning.

How Capital Health cut prohibited abbreviations by 81.5%

Capital Health, the health region that served Edmonton, Alberta, with 12 acute-care hospitals and a rehabilitation hospital, approved a list of seven prohibited abbreviations in 2004. A baseline audit identified a prohibited abbreviation or dose designation in 22.2% of medication orders. The goal was a 75% reduction.

To implement the policy, the team chose to educate first and enforce second. Pharmacists and educators delivered more than 80 face-to-face presentations, all completed by September 30, 2005. Every patient care area at each hospital site received a tool kit with posters, FAQs, chart bookmark stickers, and self-adhesive notes, so the reminder sat where people wrote orders.

It worked. Over four years, prohibited abbreviations fell 81.5% across medication and total parenteral nutrition (TPN) orders combined, and 64.4% in medication orders alone. “QD” went from 14.3% of orders at baseline to 1% by the end of the evaluation, according to the study by Horon, Hayek, and Montgomery.

The same expectation now applies across Canada. In 2009, Accreditation Canada made adopting a Do Not Use list of abbreviations a Required Organizational Practice, based on ISMP Canada’s list.

Make the safe form the default with Snippets

Capital Health’s lesson holds up. People use the safe form when it’s in front of them and easy to write. Text expansion makes the written-out term the fastest thing to type. Text shortcuts save time for professionals in many industries, and in healthcare, a text expansion tool can automate the replacement of medical abbreviations with the full term, which keeps charts readable.

With medical text replacement software like TextExpander, you save a term or phrase as a Snippet and insert it by typing a short abbreviation. Type “;msulf” and “morphine sulfate” appears. Type “;daily” and you get “daily.” The shortcut stays in your keystrokes, and the record shows the full term.

Most operating systems include basic text replacement, and it works for one person on one device. A care team needs the same approved wording on every computer, so TextExpander keeps Snippets in shared Snippet Groups. When the policy changes, someone updates the Snippet once, and everyone’s next expansion uses the new wording. That kind of automation keeps wording consistent across team communications, from orders to handoff notes.

A few setup choices matter in healthcare:

• Choose shortcuts that can’t pass for a real abbreviation. If a shortcut ever lands in a chart unexpanded, “;msulf” is obviously a typo. “MS” isn’t.
• Use Fill-ins for anything that changes. Fill-ins prompt you for the dose, frequency, or time when the Snippet expands, so the stable wording stays saved.
• Keep patient information out of Snippets. Reusable Snippets shouldn’t contain PHI. Patient-specific details belong in Fill-ins at expansion time. Read more about TextExpander and HIPAA, including BAA availability on qualified Enterprise plans.

Pharmacy teams use the same approach at scale. At Alto Pharmacy, Snippets with Fill-ins and optional sections put the correct language for medications like morphine on the right patient profiles, and patient-facing content goes through central approval before anyone uses it.

TextExpander helps quickly align a team to a particular function or a message, even processes. Having these processes already documented and presented in a standardized way aligns the team and ultimately helps us provide better service to our patients.

Roni Hein, Pharmacy Care Operations Manager, Alto Pharmacy

The Do Not Use list tells your team what to avoid. Deciding which abbreviations they can use is the other half of the job, and our guide to approved medical abbreviations covers who makes that call and how to build the list.