Uppercase and lowercase letter U mistaken as numerals 0 or 4. 2 The patient was not harmed, but failure to document the correct allergy could have risked serious harm. The pharmacist contacted the patientвЂ™s physician who identified Lodine as the allergy.

Another pharmacist thought the allergy was LODINE (etodolac). While reviewing an order for a new patient, a pharmacist read вЂњIODINEвЂќ in the space for allergies. Uppercase letter L mistaken as uppercase letter I. Similar dosing errors have occurredВ with other drugs with names that end in the letter l ( Figure 3 provides another example). The patient received several incorrect doses and developed hypotension, which required monitoring. However, she misread the dose as 12.5 mg daily ( Figure 2),В seeing the final вЂњlвЂќ in lisinopril as the number one (1). In another case, a nurse transcribed an order for lisinopril 2.5 mg daily by copying the prescriberвЂ™s orders that were previously on hold. The pharmacist processed the order correctly as 2 mg, and the error was detected when the nurse called to question why only 2 mg was dispensed. 3 The lowercase l at the end of the brand name, along with insufficient space between the last letter of the drug name and the dose, led the nurse to misread the dose as 12 mg. A nurse misread an order for 2 mg of AMARYL (glimepiride) as 12 mg ( Figure 1). Lowercase letter l mistaken as numeral 1. 1-3 A few examples of misinterpreted alphanumeric symbols that happened when reading handwritten medication orders follow. Cursive writing is most susceptible to illegibility and carries the greatest vulnerability to error, as the various symbols often lack distinctiveness. Mistaken letters and numerals play a large part in errors when reading handwritten drug names, doses, and directions.

Table 1В lists examples of commonly confused alphanumeric symbols. Since many alphanumeric symbols share similar, or identical, physical characteristics, differentiation often poses a challenge. The uppercase letter O looks like the numeral 0. For example, depending on the font, the lowercase letter l can look exactly like the numeral 1. However, problems may arise during written or electronic communication because of similarities in appearance of the alphanumeric symbols we use. These alphanumeric symbols (letters and numerals) work well most of the time when used to communicate information. Problem: The English language uses the Latin alphabet with 26 letters and a numeric system with 10 numerals.

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