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For Doctors’ Scrawl, Handwriting’s on the Wall

Georgette Samaritan, RN, BSN

Reprinted with permission from MAG Mutual Insurance Company, Healthcare Risk Manager, Volume 7 /Number 14 2001

Physicians’ handwriting has long been a joke. However, poor handwriting among healthcare providers is increasingly being diagnosed as a threat to patients. Nearly all of the prescriptions issued each year in the United States are written by hand. According to the Institute for Safe Medication Practices, indecipherable or unclear prescriptions result in more than 150 million calls from pharmacists to physicians asking for clarification, a time-consuming process that costs the healthcare system billions of dollars per year in wasted time. Experts say that up to 25 percent of medication errors may be related to illegible handwriting: A pharmacist misreads an illegible prescription; one drug is mixed up with another.

AVANDIA (rosiglitazone) or COUMADIN (warfarin)? Avandia treats type 2 diabetes; Coumadin is an anti-clotting agent used in treating heart and stroke related problems. Avandi is the prescribed drug in this case. Jury Blames Doctor’s Bad Handwriting for Patient Death In 1999, a Texas jury awarded a woman $450,000 after her husband suffered a fatal heart attack while taking the wrong medication. At issue was a prescription the cardiologist wrote for 20 mg of Isordil (for angina) every six hours. The pharmacist misread “Plendil” for “Isordil.” A day later, taking what equaled a 16 percent overdose of Plendil, the patient had a fatal heart attack. The overall quality of the care received was never an issue. The defense attorney presented compelling evidence that the medication error had not caused the patient’s death. The trial was held in a conservative part of Texas where physicians typically enjoy courtroom success.

ISORDIL(r) (isosorbide dinitrate) or PLENDIL(r) (felodipine)? Isordil is a treatment for chest pains and can cause extremely low blood pressure; Plendil is prescribed for hypertension, or high blood pressure. Isordil was the intended drug. Sending a Message with a Verdict The jury later indicated that the award would have been much higher if the patient’s lawyer had put a price tag on the case. This first negligence judgment against a doctor purely for illegible handwriting focuses on the need for system changes and provides a needed wake-up call.

TEGRETOL (carbamazepine) or TEQUIN (gatifloxacin)? Tegretol relieves the convulsions associated with epilepsy; Tequin is an antibiotic used in treating respiratory infections. The prescription is for Tequin. Addressing the Problem of Illegible Medication Orders Handwriting’s role in medication errors has not escaped notice within organized medicine. Physicians are urged to:

• Improve the legibility of handwritten orders for medications and review all orders for accuracy and legibility after writing them.

• Note the “purpose” of a prescription to avoid confusion on the part of either pharmacists or patients.

• Use direct, computerized order entry systems, or print or type medication orders.

• Evaluate new electronic point-of-care software that not only prints legible prescriptions, but also alerts doctors to potential drug or allergy interactions, using up-to-date databases of medications that are linked to the patient’s records.

• Avoid using decimals, nonstandard abbreviations or the letter “u” (which can easily be misread as a zero) as shorthand for “units.”

• Consider preprinted prescriptions, on which physicians merely have to note the dosage and add their signature and DEA number.

• Take the time to educate patients or family members about the drug and dosage ordered. The patient should be asked to repeat the information to ensure they’ve understood.