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A doctor wrote the following order for an 8-year-old boy:
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The attending nurse obtained the medication and administered the solution in each eye. Almost immediately the boy cried out in pain. The nurse was shocked and bewildered and ran to get another nurse on the unit. The other nurse quickly discovered what had happened when she saw the medication order. She knew the boy had recently developed an inner ear infection-something the administering nurse didn't know because she was new to the unit. She misinterpreted the abbreviation AU (each ear) for OU (each eye).
They called the boy's doctor who gave a telephone order for eye irrigation. The boy suffered no further ill effects in his eyes and the Colymycin was properly administered in each ear.
The best way to prevent such an error is to not use these abbreviations. But if you see it, always question the order ..