Patient Safety Reference

Dangerous Medical Abbreviations: The Australian Do Not Use List

Some medical abbreviations are banned in Australian healthcare because they have caused medication errors, including patient deaths. The Australian Commission on Safety and Quality in Health Care (ACSQHC) maintains the national reference for this. The 2024 update of the Recommendations for Safe Use of Medicines Terminology lists abbreviations and symbols that should never be used in handwritten, printed, electronic or verbal communication about medicines, with safer alternatives for each.

This guide explains why certain abbreviations are dangerous, walks through the Australian do not use list by category, and gives the recommended replacement for each one. It is built from ACSQHC guidance and the related NSW Health Medication Handling policy (PD2013_043), with international reference to the ISMP List of Error-Prone Abbreviations where AU guidance points to the same conclusion. For exact current wording, always check the live ACSQHC document at safetyandquality.gov.au.

Medication errors are one of the most common causes of preventable harm in healthcare. Australian and international research has consistently traced a portion of those errors back to the same set of unclear, ambiguous or easily-misread abbreviations. The risks fall into a few patterns.

The pattern is not that these abbreviations are wrong in intent. They are short forms that have been used in medical practice for decades, sometimes centuries. The problem is that the conditions of modern Australian healthcare (multi-clinician handovers, mixed handwritten and digital records, tight time pressures, look-alike or sound-alike drug pairs) make them unreliable. When a single misread abbreviation can change a dose by a factor of ten or change the drug entirely, the safer choice is to write it in full.

Australia has had a national reference for safe medicines terminology since 2008. The Australian Commission on Safety and Quality in Health Care first endorsed a national standard prepared by the NSW Therapeutic Advisory Group, then formalised it as the Recommendations for Terminology, Abbreviations and Symbols Used in Medicines Documentation. The most recent revision, published in 2024, is titled Recommendations for Safe Use of Medicines Terminology and is the document Australian health services should be using as the current reference.

Two practical points sit underneath the document.

Six best-practice principles sit at the head of the ACSQHC document. They are worth memorising as the rules of thumb that drive every entry in the do not use list below.

Six best-practice principles (ACSQHC, 2024)

Abbreviations of drug names are the highest-risk category in the do not use list. The ACSQHC position is clear: do not abbreviate drug names. Use the active ingredient name in full, every time, on every prescription, dispensing label, administration record, discharge summary and verbal handover.

The risk is not theoretical. Each of the abbreviations in the table below has been linked to documented medication errors in Australian or international reporting. The drug pairs they confuse are wildly different in dose, indication and toxicity profile.

Drug-name abbreviations to never use

Dose unit abbreviations are the next-largest source of medication error. They are also the easiest to fix, because the safe alternative is just the word in full. The classic offender, a handwritten U for units misread as a zero, has caused thousands of documented tenfold insulin overdoses internationally and is at the top of every safety body’s do not use list.

Dose unit abbreviations

The microgram problem deserves a moment of focus. The Greek letter mu (μ) prefacing a “g” was the historical chemistry shorthand for microgram. In handwritten prescriptions, the mu loop closes and the symbol reads as a small “m”. Reading “mg” instead of “μg” turns a 25 microgram dose into a 25 milligram dose. ACSQHC guidance is to write microgram in full where there is space, and to permit “mcg” only where space is genuinely tight.

Frequency and route abbreviations are where Latin tradition collides with modern safety thinking. Many of these have been used in medicine since the 18th century. Several remain acceptable in Australian practice (TDS for three times daily, BD for twice daily, PRN for as required), but a specific subset have been linked to documented errors and are now on the do not use list. The 2024 ACSQHC update broadened the preference for English equivalents, particularly in digital records.

Frequency abbreviations to avoid

Route abbreviations to avoid

Decimal-point errors are a tenfold dose risk and they are the easiest to prevent. Two rules cover almost every decimal-related medicines documentation error reported in Australia.

Decimal expressions: do not write versus write

Most Latin frequency abbreviations remain in everyday Australian use, but a steady migration toward English equivalents has been underway since 2008. The 2024 ACSQHC update accelerates that shift, particularly for digital medication records where there is no longer any space-saving justification for Latin shorthand.

The Latin frequency abbreviations that are still commonly accepted in Australian charting (BD, TDS, QID, PRN) are documented in our guide to common abbreviations. The table below covers the Latin abbreviations that should NOT be used, even where they remain in older textbooks or international references.

Latin abbreviations replaced by English

The Latin abbreviations that remain accepted in Australian practice (BD, TDS, QID, PRN, mane, nocte, stat) are short, familiar across the entire workforce, and have not been linked to documented error patterns. They are not on the do not use list. The discriminator is whether the abbreviation introduces ambiguity, not whether it is Latin.

Every entry on the do not use list has a defensible safer alternative. The pattern is consistent: where there is room, write it in full; where space is genuinely tight, use the safest accepted abbreviation; never abbreviate drug names; never abbreviate routes that carry high-risk consequences if confused (intrathecal, intravenous, intramuscular).

Two other patterns are worth knowing.

The Australian Pharmaceutical Formulary and the National Inpatient Medication Chart both reflect the ACSQHC recommendations. If you are looking at a chart format and wondering whether an abbreviation is acceptable, those documents are useful secondary references.

For coders, transcriptionists and quality auditors specifically, the abbreviation question matters in a slightly different way. You are not the prescriber, but you are reading what others have written. Recognising a do not use abbreviation in a record is a quality flag for clinical documentation review. Our top-100 terms cheat sheet and the prefixes and suffixes reference are the day-to-day reading tools; this article is the patient-safety lens that sits behind them.

Safe terminology and abbreviation use is part of every medical-terminology learning pathway in Australia, including TalentMed’s BSBMED301 Interpret and Apply Medical Terminology Appropriately. The unit covers anatomy and physiology vocabulary, prefixes, suffixes, body-system terms and abbreviations, with practical work on reading clinical records accurately and writing safe documentation.

If you are training for a role in clinical coding, medical transcription, practice management or quality auditing, do not use list awareness is part of professional fluency. Knowing why a record uses “0.5 mg” rather than “.5 mg”, or “subcutaneous” rather than “SC”, is part of the literacy that lets you read past the structure to the clinical meaning of the note.

For the deeper terminology fundamentals, see the medical terminology hub. For how Australian abbreviations sit alongside other terminology systems, see how to learn medical terminology and the Greek and Latin roots reference. The BSBMED301 course page has the full unit detail and current pricing.