A handwritten order for SORIATANE (acitretin) 25 mg was mistaken as LOXITANE (loxapine) 25 mg. Uppercase letter S mistaken as uppercase letter L. During investigation of the event, several other orders with a null sign revealed that the symbol could be mistaken as a 4 or 9, especially if the tail of the slash mark through the circle is long, or a 6, especially if the circle is not closed above the slash mark through the circle.
The patient was found in cardiac arrest resuscitation efforts ensued but the patient suffered anoxic brain injury. The patient received a basal infusion of morphine 4 mg/hour and became unresponsive. Two nurses misread the null sign as the number 4. A physician documented a handwritten null sign next to a dose prompt for a basal rate on a patient-controlled analgesia order form. Numeral 0 (written as Ø) mistaken as numeral 4, 9, or 6. In this case, the handwritten letter Z was misread as the numeral 2. An error-prone abbreviation for hydrochlorothiazide was used-HCTZ-and the dose was written very close to the abbreviation-HCTZ50. A handwritten order for hydrochlorothiazide 50 mg daily was mistaken as hydrocortisone 250 mg. Uppercase letter Z mistaken as numeral 2. This error occurred despite the prescriber’s avoidance of the error-prone abbreviation U for units, which has also been misinterpreted as the numeral 4 or 0. The patient required treatment for severe hypoglycemia. The mistake was made by three practitioners who either dispensed or administered the medication. The word “units” had been written out, but the letter u looked like the numeral 4, and the remaining part of the word, “nits,” was read as units. The handwritten order in Figure 4 was misread as NOVOLOG (insulin aspart) 54 units instead of the intended 5 units. Another common mix-up between alphanumeric letters and numerals involves an uppercase U or lowercase u that has been mistaken as the numeral 0 or 4 if the downward tail on the letter U/u is too long. Uppercase and lowercase letter U mistaken as numerals 0 or 4.
2 The patient was not harmed, but failure to document the correct allergy could have risked serious harm. The pharmacist contacted the patient’s physician who identified Lodine as the allergy. Another pharmacist thought the allergy was LODINE (etodolac). While reviewing an order for a new patient, a pharmacist read “IODINE” in the space for allergies. Uppercase letter L mistaken as uppercase letter I. Similar dosing errors have occurred with other drugs with names that end in the letter l ( Figure 3 provides another example). The patient received several incorrect doses and developed hypotension, which required monitoring. However, she misread the dose as 12.5 mg daily ( Figure 2), seeing the final “l” in lisinopril as the number one (1). In another case, a nurse transcribed an order for lisinopril 2.5 mg daily by copying the prescriber’s orders that were previously on hold. The pharmacist processed the order correctly as 2 mg, and the error was detected when the nurse called to question why only 2 mg was dispensed. 3 The lowercase l at the end of the brand name, along with insufficient space between the last letter of the drug name and the dose, led the nurse to misread the dose as 12 mg. A nurse misread an order for 2 mg of AMARYL (glimepiride) as 12 mg ( Figure 1). Lowercase letter l mistaken as numeral 1. 1-3 A few examples of misinterpreted alphanumeric symbols that happened when reading handwritten medication orders follow. Cursive writing is most susceptible to illegibility and carries the greatest vulnerability to error, as the various symbols often lack distinctiveness. Mistaken letters and numerals play a large part in errors when reading handwritten drug names, doses, and directions. Table 1 lists examples of commonly confused alphanumeric symbols. Since many alphanumeric symbols share similar, or identical, physical characteristics, differentiation often poses a challenge. The uppercase letter O looks like the numeral 0. For example, depending on the font, the lowercase letter l can look exactly like the numeral 1. However, problems may arise during written or electronic communication because of similarities in appearance of the alphanumeric symbols we use. These alphanumeric symbols (letters and numerals) work well most of the time when used to communicate information. Problem: The English language uses the Latin alphabet with 26 letters and a numeric system with 10 numerals.
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