Chapter 5 . The Joint Commission ’ s “ Do Not Use ” List : Brief Review ( NEW )

Introduction Medication errors stem from a variety of causes, including miscommunication between prescribers and pharmacists in the form of misunderstood and/or illegible abbreviations. The potential hazards of certain abbreviations started receiving heightened attention approximately twenty years ago. Most notably, as one of its National Patient Safety Goals, the then named Joint Commission on Accreditation of Healthcare Organizations (JCAHO, hereinafter referred to as the Joint Commission for consistency) in 2003 announced that nine abbreviations and/or shorthand notations—a Do Not Use list--should be banned in its accredited hospitals by April 2004. The list included the following inappropriate abbreviations: “U” or “u” instead of unit; “IU” instead of International Unit; “Q.D.” or similar instead of once daily; “Q.O.D” or similar instead of every other day, “MS”, “MSO4” and “MgSO4” instead of writing morphine sulfate or magnesium sulfate; and use of zeros, either when trailing an ordinal number (1.0 instead of 1) or lack of a zero before a decimal point (.9 instead of 0.9)