Error-Prone Drug Name Abbreviations


The drug name abbreviations found in this table
have been reported to the Institute for Safe Medical
Practices (ISMP) through the ISMP Medication
Error Reporting Program as being frequently
misinterpreted and involved in harmful medication
errors. These drug name abbreviations should
never be used when communicating medical
information; complete drug names should be used.

Drug Name
Intended Meaning Misinterpretation Correction
APAP acetaminophen Not recognized as acetaminophen Use complete drug name
ARA A vidarabine Mistaken as cytarabine (ARA C) Use complete drug name
AZT zidovudine (Retrovir) Mistaken as azathioprine or aztreonam Use complete drug name
CPZ Compazine (prochlorperazine) Mistaken as chlorpromazine Use complete drug name
DPT Demerol-Phenergan-Thorazine Mistaken as diphtheria-pertussis-tetanus (vaccine) Use complete drug name
DTO diluted tincture of opium, or deodorized tincture of opium (Paregoric) Mistaken as tincture of opium Use complete drug name
HCI hydrochloric acid or hydrochloride Mistaken as potassium chloride (The “H” is misinterpreted as “K”) Use complete drug name unless expressed as a salt of a drug
HCT hydrocortisone Mistaken as hydrochlorothiazide Use complete drug name
HCTZ hydrochlorothiazide Mistaken as hydrocortisone (seen as HCT250mg) Use complete drug name
MgSO4* magnesium sulfate Mistaken as morphine sulfate Use complete drug name
MS, MSO4* morphine sulfate Mistaken as magnesium sulfate Use complete drug name
MTX methotrexate Mistaken as mitoxantrone Use complete drug name
PCA procainamide Mistaken as patient controlled analgesia Use complete drug name
PTU propylthiouracil Mistaken as mercaptopurine Use complete drug name
T3 Tylenol with codeine No. 3 (acetaminophen with codeine) Mistaken as liothyronine Use complete drug name
TAC triamcinolone Mistaken as tetracaine, Adrenalin (epinephrine), cocaine Use complete drug name
TNK TNKase Mistaken as “TPA” Use complete drug name
ZnSO4 zinc sulfate Mistaken as morphine sulfate Use complete drug name
Drug Names
Intended Meaning Misinterpretation Correction
“Nitro” drip nitroglycerin infusion Mistaken as sodium nitroprusside infusion Use complete drug name
“Norflox” norfloxacin Mistaken as Norflex (orphenadrine citrate) Use complete drug name
“IV Vanc” intravenous vancomycin Mistaken as Invanz (ertapenem) Use complete drug name

*Included on The Joint Commission's “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization's “Do Not Use” list, effective January 1, 2004. For more information visit


Source: Institute for Safe Medication Practices. Error-Prone Abbreviations, Symbols, and Dose Designations. 2013.

Available at:

(Rev. 12/2014)

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