Safe Medication Order Writing The following items are required for every inpatient medication order.

. Omission of any component may result in delay of order processing. Patient name Patient medical record # Patient location (unit and room #) Date AND time Medication: name (trade or generic) dose route frequency duration indication Physician signature Always include a qualifier with PRN orders. ( e.g: PRN pain, PRN nausea, PRN temp >101o) Avoid writing mg/kgyou must determine the weight to be used AND the final dose amount. Dont scratch scratch out wordsdraw a single line through the mistake and write mistaken entry above it and initial. Please write legibly! Illegibility is the leading cause of prescribing errors. Make sure your signature is legiblespelling out your name is even better. This greatly helps when you need to be contacted.

Safe Medication Order Writing The following items are required for every inpatient medication order. Omission of any component may result in delay of order processing. Patient name Patient medical record # Patient location (unit and room #) Date AND time Medication: name (trade or generic) dose route frequency duration indication Physician signature Always include a qualifier with PRN orders. ( e.g: PRN pain, PRN nausea, PRN temp >101o) Avoid writing mg/kgyou must determine the weight to be used AND the final dose amount. Dont scratch scratch out wordsdraw a single line through the mistake and write mistaken entry above it and initial. Please write legibly! Illegibility is the leading cause of prescribing errors. Make sure your signature is legiblespelling out your name is

even better. This greatly helps when you need to be contacted.

The following abbreviations will not be used as handwritten communication at UMC: Abbreviation 1. 2. 3. 4. U (for unit) IU (for international unit) Q.D. Q.O.D. (Latin abbreviation for once daily and every other day) Trailing zero (X.0 mg), Lack of leading zero (.X mg) MS MSO4 MgSO4 g (for microgram) Potential Problem Mistaken as zero, four or cc Mistaken as IV (intravenous) or 10 (ten) Mistaken for each other. The period after the Q can be mistaken for an I and the O can be mistaken for I Decimal point is missed Preferred Term Write unit Write international unit Write daily and every other day 1. 2.

Abbreviation U (for unit) IU (for international unit) Q.D. Q.O.D. (Latin abbreviation for once daily and every other day) Trailing zero (X.0 mg), Lack of leading zero (.X mg) MS MSO4 MgSO4 g (for microgram)

Potential Problem Mistaken as zero, four or cc Mistaken as IV (intravenous) or 10 (ten) Mistaken for each other. The period after the Q can be mistaken for an I and the O can be mistaken for I Decimal point is missed

Preferred Term Write unit Write international unit Write daily and every other day

3. 4.

5. 6.

Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal Write morphine sulfate or magnesium sulfate Write mcg

5. 6.

Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal Write morphine sulfate or magnesium sulfate Write mcg

7. 8. 9. 10.

Confused for one another. Can mean morphine sulfate or magnesium sulfate Mistaken for mg (milligrams) resulting in one thousand-fold dosing overdose Mistaken for either halfstrength or hour of sleep (at bedtime). q.H.S. mistaken for every hour. All can result in a dosing error Mistaken for three times a day or twice weekly resulting in an overdose

7. 8. 9. 10.

Confused for one another. Can mean morphine sulfate or magnesium sulfate Mistaken for mg (milligrams) resulting in one thousand-fold dosing overdose Mistaken for either halfstrength or hour of sleep (at bedtime). q.H.S. mistaken for every hour. All can result in a dosing error Mistaken for three times a day or twice weekly resulting in an overdose

11. Write out halfstrength or at bedtime

11.

H.S. (for halfstrength or Latin abbreviation for bedtime)

H.S. (for halfstrength or Latin abbreviation for bedtime)

Write out halfstrength or at bedtime

12. Write 3 times weekly or three times weekly

12.

T.I.W. (for three times a week)

T.I.W. (for three times a week)

Write 3 times weekly or three times weekly

Approved by Medical Records Committee: December 2, 2003

Approved by Medical Records Committee: December 2, 2003

The following abbreviations will not be used as handwritten communication at UMC: