Error Number 155. Administering Lugol's solution into an eye

The following order was written for a patient in preparation for administration of radioactive iodine (¹³¹I:)

Ouring rounds the next morning, the doctor asked the patient how he was feeling. The patient replied: "Pretty good-except for those eyedrops you're giving me. They really hurt." Knowing that no eyedrops had been ordered, the doctor checked the medication administration record and discovered his order had been misinterpreted.

The patient should have been given Lugol's solution orally, 10 drops in orange juice. The nurse transcribing the order interpreted OJ as OD (right eye). On two shifts the patient was given the Lugol's solution in his right eye.

If the doctor had used standard abbreviations, or if he had specified the route of administration, or if the nurses had realized that Lugol's solution is not for ophthalmic use, the error could have been avoided.