International Journal of Clinical Pharmacy

, Volume 36, Issue 5, pp 1000–1006 | Cite as

The effectiveness of a ‘Do Not Use’ list and perceptions of healthcare professionals on error-prone abbreviations

  • Nithushi R. SamaranayakeEmail author
  • Dixon S. T. Cheung
  • May P. S. Lam
  • Tommy T. Cheung
  • William C. M. Chui
  • Ian C. K. Wong
  • Bernard M. Y. Cheung
Research Article


Background The use of error-prone abbreviations has led to medication errors. Many safety organisations have introduced ‘Do Not Use’ lists (lists of error-prone abbreviations that should be avoided by prescribers), but the effectiveness of these lists have not been studied. Objective We assessed the effectiveness of the ‘Do Not Use’ list introduced to the study hospital, and sought the attitudes of healthcare professionals on other potentially dangerous abbreviations (not included in the ‘Do Not Use’ list) used in prescriptions. Setting The study was conducted in a university affiliated tertiary hospital in Hong Kong. Methods An uncontrolled observational study was conducted. In-patient prescriptions were reviewed to assess the use of error-prone abbreviations included in the ‘Do Not Use’ list before, after its introduction, and following the first reinforcement. An on-line survey was also conducted among prescribers, pharmacists and nurses. Main outcome measure Rate of using error-prone abbreviations and other unapproved abbreviations among reviewed prescriptions. Results 3,238 prescriptions (23,398 drug items) were reviewed. The use of abbreviations in the ‘Do Not Use’ list decreased from 7.8 to 3.3 % after its introduction (P < 0.001) and to 1.3 % after the first reinforcement (P < 0.001). However, unapproved abbreviations were used to denote prescribing instructions in 19.2 % of the drugs prescribed. 49 different types of unapproved abbreviations were used for drug names. Conclusions A ‘Do Not Use’ list is effective in reducing error-prone abbreviations. Reinforcements of the ‘Do Not Use’ list further improves prescriber adherence. However, many other unapproved abbreviations (not included in current ‘Do Not Use’ lists) are used when prescribing. Periodic reminders on error-prone abbreviations and education of prescribers on associated risks may help to reduce the use of error-prone abbreviations in hospitals.


Abbreviations Hong Kong Medication errors Prescribing 



The authors wish to thank Dr. J. M Johnston, Associate Professor, School of Public Health, for her advice on conducting the survey.


This work was supported by the Faculty Research Fund, Li Ka Shing Faculty of Medicine University of Hong Kong received by BMYC; University Postgraduate Fellowship, Postgraduate Scholarship from the University of Hong Kong and the Wong Ching Yee Medical Scholarship for 2012 received by NRS.

Conflicts of interest


Supplementary material

11096_2014_9987_MOESM1_ESM.doc (72 kb)
Supplementary material 1 (DOC 71 kb)


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Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014

Authors and Affiliations

  • Nithushi R. Samaranayake
    • 1
    • 2
    Email author
  • Dixon S. T. Cheung
    • 3
  • May P. S. Lam
    • 2
    • 4
  • Tommy T. Cheung
    • 2
  • William C. M. Chui
    • 3
  • Ian C. K. Wong
    • 4
  • Bernard M. Y. Cheung
    • 2
  1. 1.Department of Allied Health Sciences, Faculty of Medical SciencesUniversity of Sri JayewardenepuraNugegodaSri Lanka
  2. 2.Department of MedicineThe University of Hong KongPokfulamHong Kong
  3. 3.Department of PharmacyQueen Mary HospitalPokfulamHong Kong
  4. 4.Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and ResearchThe University of Hong KongPokfulamHong Kong

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