Error-Prone Drug Name Abbreviations

ERROR-PRONE DRUG NAME ABBREVIATIONS
The drug name abbreviations found in this table have been reported to the Institute for Safe Medical Practices (ISMP) through the ISMP Medication Error Reporting Program as being frequently misinterpreted and involved in harmful medication errors. These drug name abbreviations should never be used when communicating medical information; complete drug names should be used. This includes internal communications; verbal, handwritten, or electronic prescriptions; handwritten and computer-generated medication labels; drug storage bin labels; medication administration records; and screens associated with pharmacy and prescriber computer order entry systems, automated dispensing cabinets, smart infusion pumps, and other medication-related technologies.
Drug Name Abbreviations	Intended Meaning	Misinterpretation	Correction
Antiretroviral medications (eg, DOR, TAF, TDF)	DOR: doravirine TAF: tenofovir alafenamide TDF: tenofovir disoproxil fumarate	DOR: Dovato (dolutegravir and lamiVUDine) TAF: tenofovir disoproxil fumarate TDF: tenofovir alafenamide	Use complete drug names
APAP	acetaminophen	Not recognized as acetaminophen	Use complete drug name
ARA A	vidarabine	Mistaken as cytarabine (ARA C)	Use complete drug name
AT II and AT III	AT II: angiotensin II (Giapreza) AT III: antithrombin III (Thrombate III)	AT II (angiotensin II) mistaken as AT III (antithrombin III) and vice versa	Use complete drug names
AZT	zidovudine (Retrovir)	Mistaken as azithromycin, azaTHIOprine, or aztreonam	Use complete drug name
CPZ	Compazine (prochlorperazine)	Mistaken as chlorproMAZINE	Use complete drug name
DTO	diluted tincture of opium, or deodorized tincture of opium (Paregoric)	Mistaken as tincture of opium	Use complete drug name
HCT	hydrocortisone	Mistaken as hydroCHLOROthiazide	Use complete drug name
HCTZ	hydroCHLOROthiazide	Mistaken as hydrocortisone (seen as HCT250mg)	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
Na at the beginning of a drug name (eg, Na bicarbonate)	Sodium bicarbonate	Mistaken as no bicarbonate	Use complete drug name
NoAC	novel/new oral anticoagulant	Mistaken as no anticoagulant	Use complete drug name
OXY	oxytocin	Mistaken as oxyCODONE, OxyCONTIN	Use complete drug name
PCA	procainamide	Mistaken as patient controlled analgesia	Use complete drug name
PIT	Pitocin (oxytocin)	Mistaken as Pitressin (vasopressin)	Use complete drug name
PNV	prenatal vitamins	Mistaken as penicillin VK	Use complete drug name
PTU	propylthiouracil	Mistaken as Purinethol (mercaptopurine)	Use complete drug name
T3	Tylenol with codeine No. 3 (acetaminophen with codeine)	Mistaken as liothyronine (sometimes referred to as T3)	Use complete drug name
TAC or tac	triamcinolone or tacrolimus	Mistaken as tetracaine, Adrenalin and cocaine; or as Taxotere, Adriamycin, and cyclophosphamide	Use complete drug name. Avoid drug regimen or protocol acronyms that may have a dual meaning or may be confused with other common acronyms, even if defined in an order set.
TNK	TNKase	Mistaken as “TPA”	Use complete drug name
TPA or tPA	tissue plasminogen activator, Activase (alteplase)	Mistaken as TNK (TNKase, tenecteplase), TXA (tranexamic acid), or less often as Retavase (retaplase)	Use complete drug names
TXA	tranexamic acid	Mistaken as TPA (tissue plasminogen activator)	Use complete drug name
ZnSO4	zinc sulfate	Mistaken as morphine sulfate	Use complete drug name
Stemmed Drug Names	Intended Meaning	Misinterpretation	Correction
Coined names for compounded products (eg, magic mouthwash, banana bag)	Specific ingredients compounded together	Mistaken ingredients	Use complete drug/product names for all ingredients
“Levo”	levofloxacin	Mistaken as Levophed (norepinephrine)	Use complete drug name
“Neo”	Neo-Synephrine (phenylephrine)	Mistaken as neostigmine	Use complete drug name
“Nitro” drip	nitroglycerin infusion	Mistaken as sodium nitroprusside infusion	Use complete drug name
Number embedded in drug name (not part of the official name) (eg, 5-fluorouracil, 6-mercaptopurine)	fluorouracil, mercaptopurine	Embedded number mistaken as the dose or number of tablets/capsules to be given	Use complete drug names, without an embedded number
“IV Vanc”	intravenous vancomycin	Mistaken as Invanz (ertapenem)	Use complete drug name
NOTES
*Included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. For more information visit http://www.jointcommission.org.
REFERENCES
Source: Institute for Safe Medication Practices (ISMP). List of Error-Prone Abbreviations, Symbols, and Dose Designations. ISMP; 2021. Available at: https://www.ismp.org/recommendations/error-prone-abbreviations-list. Accessed October 5, 2023. (Rev. 10/2023)

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