It’s an age-old joke that a person with lousy handwriting will become the doctor. But for some people, it’s not funny at all. There are many cases of misread prescription leading to death. As a simple Google search of “illegible handwriting of doctors cause death” gave a stunning result of 17,10,00,000 items in 0.66 seconds.
Doctors have to see hundreds of patients daily in their limited OPD hours. The situation is worst in Govt. hospitals because of the enormous mass of patients coming daily.This further worsens their handwriting when writing prescriptions. A statistical study by the Institute of Medicine of the National Academies of Science in 2006 showed that illegible handwriting caused over 7000 deaths in a year. It’s hard to say how many of such cases happen in India where we don’t even have any data on prescription errors.
1. Some classic examples of prescription error
- One of my patients with cough and cold was prescribed Laveta tablet to be taken once daily. Bad handwriting led to him taking Caverta tablet instead, which is a Viagra group of drugs.
- One patient was administered 40 units of insulin when he was to be given only four units (the nurse on duty read U as 0). “U” is often misinterpreted and read as the number “0”, leading to overdoses all the time. One of the common sources of errors are decimal points which are easy to be misinterpreted.
- A patient received 5 mg tablet Alprazolam (sleeping medicine) instead of .5mg written on a prescription (.5 was read as 5, the decimal point was missed).
- Another patient was given 10 mg of tablet Larpose when the intent was to give 1.0 mg (1.0 was misread as 10 mg). Use of a trailing zero after a decimal often causes overdose and should be avoided.
2. Popular cases of illegible writing covered by media
- A Texas-based cardiologist who was fined $225,000 for the death of his patient because his handwritten prescription for “Isordil” was misread as “Plendil,” a medication for high blood pressure.
- In 2018, the court imposed a fine of Rs. 5000 each on three doctors for bad handwriting in medical records When Lucknow bench of Allahabad high court failed to read injury remarks of victims in respective Medical records of three criminal cases, it penalized the doctors who have written the reports. The bench stated that “poor handwriting is obstruction to court work”.
- Few years ago, the daughter-in-law of the former editor of a leading publication in Assam was admitted to GNRC, suffering from convulsions. While the investigations could pinpoint no reason, a chance discovery by an attentive nurse revealed that a doctor in Delhi had prescribed her DUODIL – an analgesic, but what was bought and consumed was DAONIL – a medicine for diabetics. This caused a sudden fall in her blood sugar levels, leading to the convulsions.
3. Reduction in error with the use of printed prescription
- The researchers found an astonishing 37 errors for every 100 handwritten prescriptions, versus around 7 per 100 for those who used e-prescribing software and gave printed prescriptions.
- In electronic systems, drugs and dosages are selected from menus to prevent input errors, and pharmacists don’t need to re-enter information.
- In 2016, to avoid prescription errors, the Ministry of Health and Family Welfare notified the “Electronic Health Record (EHR) Standards 2016” to introduce a uniform system for creation and maintenance of health records by healthcare providers.
‘To err is human’, but if any error leads to loss of someone’s life, it must be avoided in any case. With mCURA: Smart OPD & informatics secretary, healthcare professionals (doctors, nurses, pharmacy assistant) have the power to battle with this very nature of making a mistake. With our SmartOPD solutions and e-Rx module, doctors can make the best of their consultation time being more focused on listening to the patient’s queries and providing a clean, concise and error-free prescription.
They can share (electronically) the same copy with the pharmacy, helping them to prepare the prescribed medication ready for a patient even before he/she reaches there. This SmartOPD adaptation serves as dual benefits for patients in the term of getting error-free prescription (digital and printed) along with reduced waiting time.