Stop U Be 4 Errors

"A recent error occurred when a nurse who was taking a patient's history recorded his insulin dose using the letter 'u' instead of the word 'unit' (Figure 1). The physician misread the 'u' as a '4' and wrote orders for doses dramatically different from what the patient had been taking (Figure 2). Although the physician also used the abbreviation 'u,' thankfully it was not misread as yet another 4. The patient received a single overdose of insulin, but fortunately was not harmed. The only safe way to express units is to write it out completely. Incidentally, another safe practice, telling patients the names and doses of drugs being administered, also played a role in helping to prevent additional errors. Further overdoses were averted when the nurse said to the patient, 'Here's your insulin, 44 units.' The patient responded, '44 units? I take 4 units!'"