Medication errors kill thousands of Americans each year. Many thousands more patients who are victims of medication errors, are lucky and escape with no lasting harm. The medical profession and pharmaceutical industry deserve recognition for making serious efforts to understand the cause of medication errors and to reduce their prevalence. Despite their efforts, however, medication errors remain a serious hazard in our health care system.

One of the well-known causes of some of the most serious incidents of medication errors, is the use of incorrect medical abbreviations by doctors writing prescriptions, or misinterpretation of abbreviations by pharmacists filling those prescriptions. The problem is a difficult one to solve because the use of abbreviations is solidly enmeshed in the culture and practices of medical professions. Abbreviations (and the names themselves) of completely different drugs used for totally different purposes, may be similar. Thus, for example, the initials “DPT” may be intended by the physician to mean demerol-phenergan-Thorazine, a combination of drugs sometimes used to sedate children, whereas a pharmacist may interpret the intials to stand for the diptheria-pertussis-tetanus vaccine. The intials “HCT,” meant as a prescription for the skin cream, hydrocortisone, has been mis-interpreted to mean hydrochlorothiazide, a diuretic sometimes used to treat high blood pressure.

While it may require a complete change of practice for many doctors, the solution to the problem of dangerous medical abbreviations, is to write the name of the drug out completely, preferably printed, and if written, legibly. The Institute for Safe Medical Practices (ISMP) has identified the use of abbreviations in prescriptions and medical charts as a hazard that needs elimination. ISMP gives an example of a case in which the commonly used abbreviation “D/C,” is sometimes intended to mean “discharge” and other times to mean “discontinue,” as in discontinue use of a particular drug. The potential danger of confusion is obvious. There are many more potentially lethal misinterpretations of abbreviations that are waiting to, and do, occur.

In addition to the ISMP, the federal Food and Drug Administration and the health care industry’s quality assurance and licensing arm, JCAHO, the Joint Commission on Accreditation of Healthcare Organizations, have highlighted the dangers to patients created by the continued routine use of abbreviations. Only when practitioners uniformly agree that the false savings of the few seconds gained by using abbreviations instead of whole words, creates excessive and unnecessary risk, will the practice end.