• Always spell the drug:Always spell the drug if you are giving telephonic instructions. Sound-alike drugs can cause confusion.

• g. the patient received Isoprin IV in place of Isoptin and nearly died.
• g. Amlopress AT/80mg; a hypertensive called up his family physician who asked him to take amlopress AT but the patient took amlopress 80 mg. After sometime he developed dizziness, flushing, palpitation, nausea, abdominal pain.

• Never write ‘U’ to abbreviate the word ‘units’: Do not write ‘U’ for units when writing prescription. Always write the complete word ‘units’. It may be mistaken as zero. E.g. never write 4U insulin. The patient may be given 40 units of insulin when the doctor meant 4 U (4 units).

• Never write the numeric after a decimal point: The use of a trailing zero after a decimal point when writing prescription may lead to medication errors. E.g. do not write 3.0 mg. There are chances that the patient may get 50 mg; 5.0 mistaken as 50 mg if the decimal point is not seen.

• Always write the numeric 0 before the decimal point:Always add a leading zero when writing dose of a drug, which is less than one. Lack of a leading zero may lead to a decimal point being missed. For example, never write .25 mg; instead write 0.25 mg. Otherwise there are chances the patient may take 25 mg in the first instance itself.

8-2-8 mistake: The time interval should be written more clearly as 8am 2pm 8pm. Or, the patient may consider it to be the number of tablets to be taken 8 in the morning, 2 in the afternoon and again 8 at night.