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FDA and ISMP Launch Campaign to Reduce Medication Mistakes

June 14, 2006 -- The U.S. Food and Drug Administration (FDA) and the Institute for Safe Medication Practices (ISMP) today launched a nationwide health professional education campaign aimed at reducing the number of common but preventable sources of medication mix-ups and mistakes caused by the use of unclear medical abbreviations.

"Some abbreviations, symbols and dose designations are frequently misinterpreted and lead to mistakes that result in patient harm," said FDA Acting Commissioner Andrew C. von Eschenbach, M.D. "This joint campaign will promote safe practices among those who communicate medical information to help avoid serious and even potentially fatal consequences of medication errors."

According to the Institute of Medicine (IOM) of the National Academies, there are more than 7,000 deaths a year due to medication errors. Mistakes can occur anywhere in the medication-use system, from prescribing to administering a drug in a variety of settings (hospitals, outpatient clinics, nursing homes, home care, etc.)

FDA and ISMP's educational campaign focuses on eliminating the use of potentially confusing abbreviations by healthcare professionals, medical students, medical writers, the pharmaceutical industry and FDA staff. The campaign will address the use of mistake-prone abbreviations in all forms of medical communication, including written medication orders, computer-generated labels, medication administration records, pharmacy or prescriber computer order entry screens and commercial medication labeling, packaging and advertising.

"We recommend that ISMP's list of abbreviations, symbols and dose designations most often associated with medication errors be considered whenever medical information is communicated," said Michael Cohen, ISMP President. "ISMP's list includes abbreviations that have been associated with medication errors reported to the USP-ISMP Medication Errors Reporting Program."

Examples of common error-prone notations that the campaign will seek to eliminate include:




Mistaken for zero, number four, cc (write as "unit")


Mistaken for IV, number ten (write as "international unit")

Trailing zero

Decimal point is missed (five milligrams should be presented as "5 mg" and not "5.0 mg") SHOULD use leading zeroes before decimal points (e.g., use "0.5 mg" instead of ".5 mg")

MSO4 and MgSO4

Can be confused for one another (write as "morphine sulfate" or "magnesium sulfate")

FDA and ISMP's campaign materials promote ISMP's list and include:

  1. a brochure to be distributed to medical professionals, the pharmaceutical industry and medical publishing professionals;
  2. a print public service ad that will be sent to professional trade publications;
  3. posters with reminders about commonly used error-prone abbreviations for healthcare facilities;
  4. an online toolkit of materials, including PowerPoint slides for presentations at conferences and meetings;
  5. a patient safety video.

Posted: June 2006

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