Error Number 111. Confusing "I.U." with "I.V."

Vitamin D2 liquid (Drisdol), 50,000 I.U. daily, was ordered for a woman who had hypoparathyroidism. Both the unit secretary who transcribed the order and the nurse who reviewed it mistook the abbreviation "I. U." (international units) for "I.V." (intravenous). And that's how the drug was scheduled.

Later, when the pharmacist sent up a dose of Drisdol in an oral syringe, the nurse thought he'd made an error. She discovered her mistake when she called to ask why the drug wasn't in an I.V. syringe.

This near miss could have been prevented if the doctor had made it clear in his order that the medication was to be administered orally. Also, he could have simply written "units"; the "I" for "international" really isn't needed. In any event, keep in mind that you'll see the abbreviation "I. U." used in certain or¬ders. Don't confuse it with "I.V.