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A doctor wrote an order for Lasix, 40 mg, 1 O.D. He meant for the diuretic to be given once daily. But a new nurse thought the period after the "0" was a slash mark and interpreted the order as "10/D." So she gave the patient ten 40-mg tablets daily.
Within a few days, the patient became dehydrated and developed an electrolyte imbalance. The error was discovered when the nurse overheard the doctor say he never expected such problems with only 40 mg of Lasix. The nurse told him the patient had been receiving 400 mg.
This error offers two lessons. First, if you have to give more than two tablets, capsules, ampules, or other form of a drug to complete a dose, check with the pharmacist or doctor. A mistake has probably been made. Second, don't accept abbreviations for "daily." The abbreviation "O.D." could also be read as "right eye"-a potentially dangerous misinterpretation if the drug is a liquid. The designation "q.d." could be interpreted as "q.i.d.," and "l/d." could be seen as "t.i.d."