Error Number 56. Abbreviating "every other day" when transcribing medication orders

An elderly patient was receiving digoxin for congestive heart failure. When he developed kidney dysfunction, his digoxin dosage needed to be reduced. So his doctor wrote the following order:

The unit secretary interpreted q.o.d. to mean once a day (q. = every; o.d. = once daily) and transcribed the order accordingly. The nurse who checked the transcription interpreted the order the same way and signed the transcription as correct.

The patient was given 0.125 mg of digoxin every day for 3 days until another nurse checked the transcription against the doctor's original order. She interpreted q.o.d. to mean every other day (q. = every; o. = other; d. = day) and called the doctor to check. The doctor confirmed that this was the dosing schedule he'd wanted. Luckily, the error was corrected before it harmed the patient.

This type of error can easily be prevented: Don't perpetuate the use of the abbreviation q.o.d. For one thing, it's frequently misunderstood, as illustrated by this example. For another, the 0 can be mistaken for an i when the order is handwritten, leading to an interpretation of q.i.d.-four times a day.

So always write out every other day when transcribing medication orders. And before using any abbreviation, ask yourself if it could be misinterpreted. When in doubt, spell it out.