Communication for Patient Safety
Challenging cases

Challenging cases

Case 1 - The case of the indecipherable orders


Lisa King, 2005


Writing orders, reading orders, transcribing orders ... written communication is a central part of in-hospital care.  It is also the place where medication errors can begin and a high-yield area for patient safety intervention!































Answer the questions below based on the orders provided.


Transcribe the orders as you read them.


How do these orders compare to orders you write or read at work?


List any errors, do-not-use abbreviations or missing information.



Potentially Dangerous Abbreviations[2]



 U, u (unit)

 Write "unit"

 IU (International Unit)

 Write "International Unit"

 Q.D., QD, q.d., qd, O.D.,OD (daily)

 Write "daily"

 Q.O.D., QOD, q.o.d., qod, E.O.D., EOD, e.o.d., eod, (every other day)

 Write "every other day"

 Trailing zero (X.0 mg)

 Write X mg

 Lack of leading zero (.X mg)

 Write 0.X mg


 Write morphine sulfate

 MSO4, MgSO4

 Write Magnesium sulfate


< (less than)> (greater than)

Write "less than"Write "greater than"

Abbreviations for drug names

Write drug names in full


Write "at"


Write "mL" (preferred) or "ml" or "millilitres"


"One of the major causes of medication errors is the ongoing use of potentially dangerous abbreviations and dose expressions. Underlying factors contributing to many of these errors are illegible or confusing handwriting by clinicians and the failure of health care providers to communicate clearly with one another."[2]


2. The Joint Commission. Sentinel Event Alert. Medication errors related to potentially dangerous abbreviations. Issue 23 - September 1, 2001. Available from:

All references for this section