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A doctor ordered the expectorant saturated solution of potassium iodide (SSKI), 10 drops in "OJ" (orange juice), to be given four times a day to a patient with pneumonia. The new graduate nurse read the handwritten order and proceeded to instill 10 drops of SSKI in each of the patient's eyes.
How could a drug that should be diluted in orange juice and given orally end up in someone's eyes? It's not so outlandish when you consider what happened: The nurse misread the sloppily written abbreviation "OJ" as "OU" (each eye). She must have assumed SSKI was an irrigating fluid for the eyes. Unfortunately, the patient developed chemical conjunctivitis.
This kind of mistake happens more often than you might think. Consider these examples of how OJ could be misread:
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Besides the obvious remedy-avoiding the abbreviation OJ-you can ask your pharmacist to do one of two things: Label dropper bottles of SSKI with "For oral use only" or "Do not use in eyes," or supply a prediluted potassium iodide solution that negates the need for orange juice.