The silent risk in every script: Unsafe medical terminology

A gold standard for medication prescribing terminology and abbreviations

Are you a doctor, pharmacist or healthcare professional with medication prescribing or dispensing responsibilities? Or, perhaps, you are a medical writer, educator, examination writer or researcher involved in writing clinical scenarios, reporting on clinical data or undertaking similar projects that require you to use abbreviations, dose expressions and symbols for medication?

If you are any of the above, you will find the Australian Commission on Safety and Quality in Health Care’s Recommendations for safe use of medicines terminology an invaluable guide.

Understanding the risks associated with the language of prescribing

In healthcare, clear communication is essential for the safe prescribing and administration of medicines. However, the use of medical terminology, abbreviations, and symbols - while often convenient for clinicians - can introduce risk when misunderstood or misapplied.

Medication errors are among the most commonly reported clinical incidents in acute healthcare settings. While serious harm is relatively rare, their frequency remains a concern - especially given that many are preventable. A key contributor to these errors is the use of unsafe abbreviations and unclear dose expressions.

The language of Latin is wearing thin, even among our highly educated health care professionals. Plain English is preferred.

Illegible handwriting or electronic input data, especially when combined with non-standard abbreviations, can compromise patient safety. Mixing up Latin abbreviations such as “qd” (once daily) versus qid (four times daily) and other abbreviations such as “IU” (international units) versus “IV” (intravenous) have been linked to medication errors due to misinterpretation, leading to dangerous dosing errors.

ACSQHC guidelines set the standards for best practice in Australia

The Australian Commission on Safety and Quality in Health Care (ACSQHC) has issued best practice guidelines - Recommendations for safe use of medicines terminology - to reduce such risks, which includes a list of common ‘error-prone’ or unacceptable abbreviations for medicine names and chemical names that should be written in full in clinical practice.

This guidance outlines key principles for the safe, clear, and consistent use of medicine-related terminology. It provides recommended terms, abbreviations, and dose expressions to support safe prescribing and communication. The ACSQHC recommendations apply to all medicine-related materials—whether handwritten, pre-printed, or electronically generated or displayed—as well as verbal communication within Australian hospitals and health services.

Originally published in 2016 (as Recommendations for terminology, abbreviations, and symbols used in medicines documentation), the guidance was updated in 2024 to:

• Improve the distinction between the use of terminology and abbreviations in paper-based versus digital environments
• Clarify the scope regarding digital devices
• Add more examples of abbreviations and symbols to avoid
• Expand guidance on terminology for modified-release medicines

The ACSQHC guidance is supported by a Fact Sheet, which summarise the Best Practice Principles and list of acceptable terms, abbreviations and dose designations: Fact Sheet - Recommendations for safe use of medicines terminology

Ongoing challenges

Inconsistent adoption across healthcare settings continues to pose challenges - particularly in high-pressure environments like hospitals and emergency departments. Further complexity arises from the globalisation of medical information. Healthcare professionals in their own national contexts may encounter terminology from international sources that is inconsistent with local practices, increasing the likelihood of confusion, especially in multidisciplinary teams or digital systems with mixed language inputs.

To mitigate these risks, health services are encouraged to adopt standardised prescribing practices, implement robust electronic prescribing systems, and provide ongoing education and audits around safe communication. In Australia, the ACSQHC guidelines set the standards for best practice.

The takeaway

Ultimately, clarity saves lives. Reducing ambiguity in medical language supports safer care, protects patients, and promotes better understanding by patients and their carers of medication instructions and warnings about medicines - which is more likely to lead to a patient’s acceptance of a health practitioner’s advice and adherence to a medication regime.

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References

Australian Commission on Safety and Quality in Health Care (2024). Recommendations for safe use of medicines terminology (fact sheet). https://www.safetyandquality.gov.au/publications-and-resources/resource-library/fact-sheet-recommendations-safe-use-medicines-terminology

Australian Commission on Safety and Quality in Health Care (2024). Recommendations for safe use of medicines terminology (guidelines). https://www.safetyandquality.gov.au/publications-and-resources/resource-library/recommendations-safe-use-medicines-terminology

Raban MZ, Merchant A, Fitzpatrick E, Magrabi F (2023). Recommendations for terminology, abbreviations and symbols used in medicines documentation: A rapid literature review. Macquarie University, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences. https://www.safetyandquality.gov.au/publications-and-resources/resource-library/recommendations-terminology-abbreviations-and-symbols-used-medicines-documentation-rapid-literature-review

Wittich CM, Burkle CM, Lanier WL (2014). Medication errors: An overview for clinicians. Mayo Clinic Proceedings, 89(8): P1116-1125. https://www.mayoclinicproceedings.org/article/S0025-6196(14)00439-X/fulltext