Pharmacy Newscapsule

The Pharmacy Newscapsule is a newsletter that is published regularly by the Division of Quality Assurance (DQA). This newsletter is a means of providing up-to-date information to staff who survey health and residential facilities regulated by DQA.

The material is presented with a "surveyor focus", however, the information has been informative and helpful to providers and others as well.

DQA Pharmacy Newscapsules


Disclaimer: Efforts are made to assure accurate information is contained in these newsletters, but accuracy cannot be guaranteed. The content in these newsletters is intended to be used as an informational tool by DQA survey staff and is not intended as a directive to providers regarding care for patients or residents.

Common Medication Errors

There have been several serious medication errors that have resulted in Class A and B violations for health care facilities in the state. Most of these are easily avoided with proper written orders. Listed below are the most common errors that were cause for concern:

  1. Do not use U to abbreviate the word units when ordering medications. An error found was Insulin 4U that was taken as 40 units. Always write out the word units.
  2. Do not use a trailing zero when writing orders. Another error involved the dose of 5mg that was written 5.0mg and the period was not seen. In this case 50mg or ten times the dose was given.
  3. Do use zero to begin a number less than one. An order for one tenth of a drug was written .1mg and the patient received 1mg. If the order was written as 0.1mg, this should not have happened.
  4. Another source of error is the abbreviations for every day (q.d.), every other day (q.o.d.), and four times a day (q.i.d.). In several instances the period in q.d. was mistaken for an i and the drug was given four times a day and not daily. The opposite has also occurred.

Contact Us

Comments can be directed to Doug Englebert, Pharmacy Consultant at 608-266-5388.

Last Revised: December 18, 2018