Errors while writing orders

"An order was written for '1.25 mg of Toradol x 1,' or so it seemed (Figure 1). Despite a spelling error (Tordol), that's the way a pharmacist initially read the transcribed telephone order (see below). Since the dose didn't make sense, the pharmacist checked with the transcribing nurse, who responded by saying she'd numbered the order for 25 mg of TORADOL (ketorolac) IV using the number 1 followed by a period. Errors are possible whenever numbers or extraneous marks precede drug orders. Avoid the temptation to number orders, even on preprinted order forms. We see no reason for it, but if orders must be numbered, each digit should be circled. In the past we've published cases where initials, letters, checkmarks, and other incidental marks used during ordering or transcription of handwritten orders can obscure or change how a medication order appears."