Death by prescription: How doctors’ sloppy handwriting causes avoidable drug dispensing errors

 A doctor’s handwriting can mean the difference between life and death for a patient, as sloppily written prescriptions can be misread or dosage wrongly interpreted. TESSY IGOMU reports

For minutes, Kingsley Onuoha, a pharmacist in Ajao Estate, Lagos, stared at a doctor’s prescription handed to him by an agitated female customer.

Frustrated after several failed attempts to guess the names and dosages of the drugs scribbled on the paper, the pharmacist returned the note to the customer.

“You don’t have the medicine or is it too expensive?” she asked, with a worried expression.

Continuing, the obviously exasperated customer added, “This is the third pharmacy I have been to. My son needs the drug urgently.”

The pharmacist, who was already attending to another person, simply told her to return the prescription to the doctor and have him write another one that could easily be read.

A killing machine

Getting to decipher some doctors’ prescription notes can sometimes prove herculean for patients, pharmacists and even fellow physicians.

To many people, it has become an accepted ‘fact’ that doctors don’t have perfect handwriting. The question, however, is whether it is an intentional act meant to discourage self-medication on the part of patients, or whether it is done due to work pressure or it is an innate gift peculiar to them.

Whatever the reasons behind doctors’ usually illegible scribbles, the danger it poses to everyone concerned is alarming, as PUNCH Healthwise discovered that it causes medication errors that kill hundreds of people globally.

According to non-profit organisation Medscape India, which spearheads a campaign to address the issue, the number of fatal incidents due to doctors’ unreadable prescriptions is internationally on the rise.

It noted that doctors’ illegible handwriting in medical records or medical prescriptions could put patients at risk as they may end up receiving wrong treatment.

“The staff struggling to read the doctors’ notes may write the wrong medication for the patient.

“Most of the chemists don’t have full-time pharmacists, resulting in the uneducated salesman handling prescriptions.
“With an illegible prescription and an uneducated salesman, the concoction could well be catastrophic.

“In all the final analysis, the patient becomes a victim of combined negligence,” the online portal stated.

A 2001 British paper reported that more than 10 per cent of handwritten prescriptions contained errors; while U.S. studies have found that 20 per cent of prescriptions or more were unreadable or readable only with effort.

Based on a 2006 report by the National Academies of Science’s Institute of Medicine, in the U.S. alone, doctors write about 3.2 billion prescriptions annually, but poor handwriting on such notes leads to over 7,000 deaths and 1.5 million medical errors.

The association noted that many of such errors result from unclear abbreviations and dosage indications that make patients unable to understand which medication needs to be consumed and in what amount.

It further noted that fatalities also arise when “pharmacists misunderstand or mis-record medication names or dosages conveyed messily on paper or hurriedly by phone.”

“The sloppy handwriting makes everything so confusing that despite the prescription from the doctor, the pharmacist is unable to understand the name of the medicine and the patient is unable to understand whether he is given the right medicine or the wrong one.

“In the end, the patient is the one who suffers. If the medicine is consumed more than required, there is bound to be complications as over dosage also leads to the death of the patient,” the association stated.

Based on reports, doctors’ scribbled notes were meant to keep a personal record of a patient’s medical history, and were generally seen only by the doctor However, with dozens of other professionals having to work together over time, doctors became one element of a large, multidisciplinary healthcare team.

The result of this expansion, our correspondent learnt, is that illegible scribbles, hurriedly composed by rushed doctors, are now presented to colleagues with no qualifications in cryptology.

According to an editorial in BMJ, a peer-reviewed research journal, authored by Leape and Berwick, handwritten medical notes were called a ‘dinosaur long overdue for extinction.’

The journal noted that in 2005, three surgeons audited the legibility of 40 randomly selected operative notes from an orthopaedic ward in a large British hospital.

BMJ stated that two nurses, two physiotherapists and two medical house officers were asked to rate the legibility of the notes as ‘excellent,’ ‘good,’ ‘fair,’ or ‘poor.’ Their findings showed that only 24 per cent were rated ‘excellent’ or ‘good,’ and 37 per cent were deemed ‘poor.’

Bane of the medical profession

Admitting the possibility of unreadable doctors’ prescription causing deaths, a General Practitioner, Dr. Edward Chukwurah, said such sad occurrences will continue to be the bane of the medical profession as it has become an all-comers affair.

Chukwurah said, given the number of deaths reported to have been recorded in the US alone by illegible doctors’ notes, several millions of lives are potentially in harm’s way worldwide.

“We can’t just imagine what would be happening in Nigeria or Africa, where documentation and data collation are practically non-existent,” he added.

The physician said the major challenge with a badly written doctor’s prescription is that another physician might find it difficult to decipher. He said in some instances, several doctors will have to critically look at such notes together, to guess what was prescribed.

Dr. Chukwurah said from the patient’s perspective, illegible handwriting can delay treatment and lead to unnecessary tests and inappropriate drug doses, which, in turn, can result in discomfort or death.

“When a patient is referred to my hospital and the accompanying notes are unclear, I usually place a call to the doctor for verbal clarification.

“Sometimes, doctors get overwhelmed by a patient’s complaints and would just scribble prescriptions to possibly dismiss the person.

“This is most often done in government hospitals by house officers. But in private practice, it is usually difficult because it would do more harm than good to the hospital’s reputation.

“As a patient, if you are given a prescription that is difficult to understand, there is nothing wrong to seek clarification.

“People have brought prescriptions purportedly written by doctors to me and I could barely read them. The best I could do was to refer them back to the doctor to simplify what has been written,” Chukwurah said.

Unhealthy rivalry

The medical practitioner, however, said fatalities from sloppy handwriting could be caused by error in dispensing medication by pharmacists.

“I am not exonerating our poor handwriting,” he interjected. “When a doctor’s prescription is taken to a pharmacy, the pharmacist, who is left confused by the zigzag patterned writing, could just give drugs based on the symptoms presented by the customer. This is totally wrong.”

Chukwurah said professionally, when a doctor prescribes, a pharmacist is expected to dispense, advise, recommend and even ask questions where necessary.

The physician said, unfortunately, the good relationship between doctors and pharmacists seems to have been soured due to unhealthy rivalry

“Pharmacists now refer to themselves as ‘PharmD’. They now see themselves as doctors and even prescribe drugs. The only thing they can’t do is to cut and stitch.

“Even laboratory operators now prescribe because it is a free market. In an organised society, you can only buy over-the-counter drugs, but prescription drugs can only be accessed with a signed and stamped doctor’s note,” Chukwurah added.

The medical practitioner, however, said most deaths and medical errors recorded might not necessarily be blamed on sloppy handwriting, as psychological makeup of patients could also play a role.

Chukwurah noted that unfriendly disposition of some doctors might make a patient not to trust the efficacy of a drug prescribed.

“Some doctors wouldn’t even exchange pleasantries with a patient. Once they coldly ask some questions, they would just scribble away without conversing with the patient.

“Such attitude can make the patient not trust the doctor’s judgement. Eventually, when the patient takes the drugs, he or she might not feel better because of the perceived unfriendliness.

“In my 36 years of practice, I have come to realise that certain ailments don’t require drugs, but just counselling. A simple advice like ‘take a rest’ and ‘drink lots of water’ can do the magic of healing,” he said.

‘Pharmacists not culpable’

Managing Director of Larry Way Pharmacy, Lagos, Mr. Lawrence Ekeh, disagreed that those in his profession are culpable in any reported death or medical error caused by doctors’ illegible handwriting, stressing, “A pharmacist doesn’t just assume.

“No trained, qualified pharmacist would dispense a prescription that is not comprehensible. We will always insist on doing the right thing.

“The question is, what are you dispensing and do you want to dispense your way to jail?

“The best that can be done is to call the doctor’s attention to your observation and let him explain or simplify the prescription.

“In a situation where the doctor insists that a prescription stands as stated, even when there is suspected drug-drug interaction, the pharmacist is duty bound to dispense, but the note must be endorsed by the physician.

“That way, you will remove yourself from possible blame.”

Ekeh noted that for most doctors, anyone can dispense drugs, irrespective of the professional background.

“They don’t care if the person is an auxiliary nurse or hospital attendant. Most times, these people are cowed and intimidated to dispense in whichever way they understand.
“The mistake, at the end of the day, will now be laid at the doorstep of trained pharmacists,” the pharmacist added.

Ekeh admitted that he had come across several doctors’ prescriptions that were incomprehensible, adding “It’s like they write in Arabic language.

“Let’s be clear about this: they expect a pharmacist to understand anything they write. A doctor’s writing doesn’t have to be in long hands, but the meaning should be conveyed at a glance.

“For instance, some doctors can write paracetamol in full, while others might just scribble PCM. Every pharmacist knows what PCM means, and this is part of the many terminologies every pharmacist knows.

“Since life is at stake here, the bottom line is for doctors to write what can easily be read and understood.

“The belief is that while doctors are trained to write unreadable notes, pharmacists are trained to decipher them. They shouldn’t write funny looking things and expect us to be magical about it.”

Pharmacists trained to understand medical terminologies

Another pharmacist, Kingsley Ireigwe, agreed that deaths and disabilities could arise from illegible prescription notes, adding that it could either be that a pharmacist dispensed wrongly or is unable to decipher the doctor’s handwriting.

He corroborated Ekeh’s claim that pharmacists are trained to understand medical terminologies used for prescriptions, and that certain abbreviations are constant in medicine and shouldn’t be mistaken.

“That is why they are referred to as pharmacists,” Ireigwe added.

“If, for instance, there is five over seven in a prescription note, what it means is that the medication should be taken twice a day, morning and night for five days.

“Probably, the seven now looks like nine or any other figure. But even at that, once a pharmacist can’t decipher or notices that something doesn’t tally in a prescription brought by a patient, he is obligated to get back to the doctor.

“That is why doctors would always insist the mistake is a dispensing error from a pharmacist, because whoever is dispensing should understand medical terminologies.

“This explains why a pharmacist is not meant to honour a prescription that doesn’t have the name, signature and place of practice of a doctor, and which must be on a prescription pad.

“This way, if there is an error, there can be a two-way communication. The two professions are structured in a way to have checks and balances.”

Ireigwe, however, said, “That doesn’t negate the fact that doctors could make mistakes. Some have terrible handwriting. Even when they write while not consulting, it is very glaring.

Unfettered access to prescription drugs

Ireigwe bemoaned the lack of regulation that allows unfettered access to prescription drugs, and called on relevant agencies to ensure that there is strict compliance with set pharmaceutical guidelines.

“If a drug is prescription only, it should not be sold over the counter. In a place like Nigeria where we have lots of pharmacies being operated by non-pharmacists, you can’t really control what happens.

“However, there are still places where pharmacists follow the rule.”

Pharmacists blamed

Explaining why doctors’ writing could be illegible, a general practitioner in Lagos, Dr. Cindy Madu, said most physicians write fast, noting that it might have been influenced by the need to write in shorthand while in medical school due to the pressure to meet up.

“It is not deliberate. I don’t think any doctor will, on purpose, want to jeopardise the life of a patient,” she defended.

“Sloppy handwriting doesn’t have to do with any particular profession. However, in medical school, things are usually done in a rush, but I can still tell you that there are several doctors whose writings are readable.

“If they are not, I don’t think nurses can dispense drugs in private hospitals.”

Just like other medical practitioners that blamed pharmacists for either misinterpreting or dispensing errors, Cindy said they can’t be exonerated.

She noted that when a doctor prescribes, a pharmacist is meant to vet what has been written.

“Sometimes, they could notice that there might be adverse drug reactions and draw attention to it.

“Pharmacists are the ones at fault. A patient or pharmacist has the right to demand to know what was prescribed. You can’t just give out drugs when you are not sure of what has been written.

“Just because they want to sell doesn’t mean they have to assume and dispense drugs. Getting clarifications on writings that are unclear will go a long way in curbing needless deaths,” she said.

On her part, a Family Physician at the Federal Medical Centre, Makurdi, Benue State, Dr. Laadi Swende, said sloppy handwriting is not peculiar to doctors, but that physicians write fast most times due to work pressure.

“But because a lay man doesn’t understand a doctor’s writing doesn’t make it illegible.

“It is not good to generalize and say that all doctors have bad handwriting. Majority of medical prescriptions are difficult to read, but it shouldn’t be that way.

“Readable prescription doesn’t only protect the patient but also the doctor, who might be accused of malpractice in case of wrong medication. Ideally, a pharmacist, when presented with prescriptions that are unclear, is expected to get in touch with the doctor or give the prescription back to the patient to get clarification.

Adopting e-prescription

Meanwhile, several countries have embraced electronic documentation and printed doctor prescription as the safer option, as it not only provides clarity but also constitutes a database of medication that the patient has taken over the years.

Renowned medical researcher in neurocardiology and neurosciences, Dr. Njemanze, noted that illegible handwriting causes loss of information and prevents better care for patients.

He said as much as embracing technology is the new normal, caution should not be thrown into the wind to avoid physicians not accepting responsibility for medical negligence.

He, however, said adopting both written and e-prescription would help to save lives.

“There is a legal clause to electronic prescription. When you write, you can be held liable and there is a proof in court when there is a problem.

“Inasmuch as electronic prescription is acknowledged by a doctor, it can be altered. If anything goes wrong, the doctor can wriggle out of it.

“Once you prescribe electronically, then you are removing the accountability. The doctor can claim to have written for a prescription to be taken three times a day, but that it was changed to only once, thereby resulting in medical error.

“But with manual writing, the doctor gets to append his signature,” Njemanze said.

He, however, advised that prescriptions be written in a case file as backup and then documented electronically and transferred to the pharmacist.

“At the end of the day, a good handwriting remains an asset and doctors should seek to ensure that prescriptions are legible.”