Think Twice Before Using This Abbreviation

A pharmacist attending the code called the pharmacy and asked then to urgently “prepare t-PA.” Because the call came from radiology and the prescribed dose and indication were not communicated, the pharmacist believed it was for the restoration of central venous catheter function, because calls from radiology were often for this purpose, so he dispensed a 2 mg/2 mL syringe of alteplase (Cathflo Activase) instead of the needed 100-mg dose. Because Activase, TNKase, and reteplase (Retavase) are all tissue plasminogen activators, never use/accept drug name abbreviations, and in particular, eliminate the use of the term “t-PA” in verbal, written, and electronic communications. For a full listing of error-prone abbreviations to avoid, see http://www.ismp.org/recommendations/error-prone-abbreviations-list.5 Because alteplase is used for the management of ischemic stroke and pulmonary embolism and TNKase (tenecteplase) is not, prescribers should be required to state or select an indication as part of the complete communication of the order.2,4,6,7