Medication Approved Abbreviation and Notation Safety
Key Points
- Medication documentation should use only approved abbreviations and standardized language.
- Error-prone abbreviations on do-not-use lists increase risk for patient harm.
- Spelling out medication names, frequencies, and comparison terms improves safety.
Equipment
- Current organizational approved-abbreviation reference
- Organization do-not-use abbreviation list
- MAR and documentation interface
- Clinical communication escalation pathway for clarification
Procedure Steps
- Review active documentation standards before medication charting.
- Document medication administration using approved abbreviations only.
- Avoid high-risk abbreviations on do-not-use lists.
- Spell out medication names when abbreviation confusion risk exists.
- Write frequency terms in full when possible (for example daily, at bedtime).
- Avoid ambiguous symbols in medication documentation.
- Use words instead of comparison/operator symbols (for example more than/less than, increase/decrease).
- Recheck entries for clarity and potential misinterpretation before finalizing.
- Clarify unclear orders/documentation immediately using established escalation channels.
- Reinforce standardized notation practices during handoff and peer review.
Common Errors
- Using do-not-use abbreviations → misread orders and high-severity medication errors.
- Relying on symbols and shorthand → ambiguous interpretation across team members.
- Abbreviating similar medication names → look-alike/sound-alike confusion.
- Skipping entry review → preventable documentation-related harm.
Related
- medication-administration-documentation-and-reassessment - Safe terminology supports accurate post-dose charting and response tracking.
- medication-error-reporting-and-escalation - Terminology errors should trigger immediate safety reporting and correction.