Some of the most catastrophic medication errors can be caused by simple misinterpretation symbols or abbreviations. Recognizing this long-appreciated but still-prevalent fact, the Institute for Safe Medication Practices (ISMP), has crafted suggested guidelines to reduce errors of mis-interpretation. Examples include never using trailing zeros; i.e., writing 5 mg, never 5.0 mg, which could be mistaken for 50 mg. Correspondingly, always using leading zeros; i.e., writing 0.3 mg, never .3 mg, which could be mistaken for 3 mg. Other examples are such common sense suggestions as spelling out the word “Units” and never using the abbreviation “U,” which is often misread as a zero (causing a ten-fold overdose), writing drug names out rather than abbreviating them (many abbreviations for drugs of vastly different purposes are similar and can be easily misread), and avoiding commonly misread symbols such as slash marks and hyphens. Of course, the best guidelines imaginable are of no use without implementation. Creating uniformity and the avoidance of time-saving but potentially deadly shortcuts throughout our healthcare system is a daunting, ongoing challenge.