A Dangerous Business





There was this disturbing news in yesterday’s daily which prompted me to write this.

A couple was undergoing treatment for infertility for the last few years, and finally conceived. Everyone was happy,  the patient,her husband, the doctor, and the whole family. The doctor then prescribed a medication for the safe continuation of the pregnancy. She was asked to take one tablet daily for a month. About a week after taking the medicines, the patient started feeling unwell. At the end of the course of medications, she attended the doctor for review, and he gave another  prescription to continue the same medication for a further two weeks. She couldn’t continue the medications because of severe side effects and was admitted to the hospital. It was then they found that the woman was taking a wrong medication all along. She was supposed to take a hormone to sustain the pregnancy, but received a medication to induce abortion!!And the strangest thing is that the wrong medicine, which should have induced an abortion in few days, was ineffective, even in its proposed function. The drug was also capable of inducing malformations and birth defects in the baby, and so the pregnancy had to be terminated.

This was really disturbing news to me. Further reading into the matter revealed that the prescription was grossly illegible and the pharmacist mistook it for another medicine.

At the hospital where I work, we have faced similar problems many times,and still do. Some doctors appear to be decided they will write only illegible notesand prescriptions. Even when relaxed and comfortable, some of them appear to become frantically busy when they write prescriptions. The result is an illegible tangle of lines. The pharmacists sit scratching their heads and ultimately call the doctor himself for help. Many times we had patients who were brought unconscious after taking Diamicron ( a tablet for diabetes) instead of Diovan ( medicine for BP),and also life threatening bleeding problems after taking wrong dose of warfarin ( a blood thinner used in heart disease).I have often wondered why some doctors write this way. Even those who have reasonably good handwriting, fails to make legible prescriptions. This, I would say is a fatal negligence. The time of secrecy in prescriptions is a long forgotten story. Doctors should be aware that they are answerable for such  negligence and could be held responsible.

A Texas cardiologist was probably the first doctor held liable for a fatal medication mix-up caused by this long time problem of bad handwriting. A jury in Odessa, Texas, ordered Ramachandra Kolluru to pay $450,000 to the family of Ramon Vasquez, who died after a pharmacist misread Kolluru's writing. The 42-year-old heart patient was given the wrong medication at eight times the recommended dosage. Two weeks later, he was dead from an apparent heart attack.

The victim's widow, Teresa Vasquez, says she sued to prompt doctors and pharmacists to be more careful. If the doctors don't change their writing, then it could happen to me again with my kids or even me,'' she says. Now, ''doctors might change, and it might not ever happen again to anybody. We had no complaint about his (Kolluru's) care. In fact, he is a good doctor”

The case points to a growing danger as medications become more numerous and their names more similar. Such cases go unanswered in India, probably because patients do not know they have the rights to complain about this. In the case I had mentioned, the family opted not to complain, and prayed doctors to be more careful.

From prescriptions to physician signatures, and from progress notes to referral letters, bad handwriting is a concern in every aspect of patient care. Pharmacists must be able to read medication orders, nurses must be able to determine whom to ask if they have a question about an order, and other physicians must be able to extract information efficiently from patient charts. In a 1986 study from the New England Journal of Medicine, out of 50 outpatient progress notes, 16% of all words were illegible. Only14% of the 50 outpatient progress notes had legible signature. Poor handwriting by physicians is riskier than poor handwriting by other professionals.

There are simple solutions to a dangerous problem. Many of the doctors can write legible prescriptions, if they take care. An assistant with good handwriting in the physician’s clinic could write the prescription as directed by the physician, then have the physician sign it. The drawback to this being that someone must pay the salary of the prescription writer.

The capability of pharmacists to decipher illegible calligraphy is known as to be almost proverbial. But then, we have another problem. Most of our pharmacies do not have qualified pharmacists. They get the pharmacy licence on someone’s name, but employ salesgirls or boys on low salary who probably have only school education. And on top of all this, more than 30% of all medicines sold are supposed to be fake medicines. Frightening combination, isn’t it?


can you read?
a good example





Bad writing is more like bad manners than
bad features: it is unpleasant to the
beholder, like an ugly face, but, unlike it, is
easily corrigible.
- E.W. Playfair

Comments

  1. Excellent point, doc. I have come across most doctors who enjoy scribbling some rubbish on prescriptions. I fail to understand how they cleared their exams if they wrote so illegibly. As you rightly said, bad handwriting is like bad manners. Great point raised by a doctor. I hope other doctors read this.

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  2. Interesting post Dr. Antony. May be Indians can take a lesson on this from USA. Nowadays, in USA, the prescription from the doctor’s office is computer communicated (no handwriting) to the preferred pharmacy of the patient. So no bad handwriting mistake. Oops. No handwritten prescription at all. India, world leader in software, can implement this very easily, if they want to.

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  3. doctors bad handwriting is a city joke now.

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  4. a few doctors that I used to go to...have a handwriting that was so neat and beautiful. I used to wonder - ho are they having a lot of time in their hand. I stand corrected.

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  5. Also a joke here in England with our GP being one of the worst I know. I don't know about where you practice but here doctors and in paticular junior hospital doctors work very long hours sometimes 70+ a week and I think that mistakes are also made this way.

    On a lighter note, I just thought I'd let you know that my post today answers your question about how I choose the books I read.

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  6. It is those who hadn't done their copy writing in primary classes who become doctors! Weak joke apart, this is a terrible thing. It is part of the casual and arrogant approach some doctors have, I think. I shudder to think what'd have happened to many of the rural, illiterate people who insist on modern medicine even for a minor ailment!

    Very pertinent post, Doc!

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  7. This is really scary !It is a common practice out here that the pharmacists calls up the Dr if they fail to read the prescribed drugs.

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  8. Excellent post and really true..

    I ask my doctors about the medicine when ever they write some thing I cant read.

    so sad about that pregnant lady...

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  9. true .you scared my witts out!should be extra careful ...the worst part is the pharmacist i feel ;they have to double check or clarify their doubts definetely .I see in India ,anyone can be a pharmacist,this profession can be hierarchy as if it was some 'restaurant 'or bakery business!:)

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  10. In US the prescriptions are sent electronically ..infact today I was at doctors office for my son who had some eye infection so it was at pharmacy in few seconds...there are no misunderstandings!
    "But humans can still make mistakes"

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  11. Dr. Antony,

    USA is moving to e-prescription. Drug and dosage is directly communicated using internet to Pharmacy (Chemist) for patients to pick.

    Typically I used to check the purpose of medicine from doctor and double check at pharmacy.

    Doctors need to communicate clearly verbally with clean legible handwriting.

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  12. There is a slap stick comedy about this in a Tamil cinema. "Vicks" is prescribed by a wannabe doctor and his handwriting is illegible. When prompted he says he is "getting trained" to become a doctor.

    Its sad. Take this case. Years of infertility treatment, the trauma the patient and family undergoes, the money spent and when she conceives, the doctor goofs up! e-prescription is the way!

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  13. Dr.Anthony, Its a sad news that someone who had been trying to conceive was given medication for termination.
    I can think of couple of things, give it a thought and let me know.

    1. More often than not, doctors are over-worked. that is a known fact. It could be due to fact that they want to earn lot more in short period of time (like seeing 30 patients a day instead of 20) or a long line of people waiting for assistance.

    What I think could be done is, just like we have monitors at the check-out counters in shops, which display a list of items, even doctors can have a software which will enable them to choose the medication on computer and print the prescription. That way, we can target the hand writing problem and printing is done fairly quick. So, no wastage of time. Of course, we would need custom built software for this but I am sure some 10 lacks wouldn't be too much for a hospital to bear.

    2. Your idea of employing someone as assistant is great. There is no downside to it actually. What happens in Canada is that, if you happen to be final year medical student, a practicing doctor can allow you to stay with you in the consultation room. While you are examining the patient, the student is having hands on experience in seeing real cases. When the doctor is prescribing the medication, its the student who writes it up. Before giving it to the patient, the doc cross checks everything.

    But I agree with others, e-prescription is the way to go.

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  14. Very pertinent post. I have had few problems myself with the paediatrician when my kids were small. I used to write it in my own hand writing in some other paper. This can be really scary.
    I wonder whether e-prescription would work in India right now. Think about the local doctors in smaller towns and districts. Will they and the pharmacists there have access to computers? May be it should be mandatory to write the name of the medicine in block letters.

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  15. This is a very interesting post. This reminds me of how scared I was when prescribed heart medicatioin but I am okay. I know one thing, I can't read my doctors handwriting.

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  16. Dr.Antony , I am shocked to read about serving wrong medication..Doctor failed..pharmacist failed..patient could not figure out...and damage was done.

    It is unacceptable that Doctor's badly scribble prescriptions...system change is not very easy in India...so it is better if Doctor and pharmacist take proper care while administering right medicine to patient...Also patients must make sure they take right medication.

    When I was growing up in Mumbai I remember, we used to buy medicine and take it back to doctor then he would advise about dose..This was good system..I wonder why it is stopped now.

    Thanks for visiting and following my blog..It will be pleasure to read your blog in future. :)

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  17. Wonder if ever a doctors hand writing has been read as"Viagra" instead of Valium!!!
    Doc absolutely relevant post.

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  18. excellent post.
    in India here we do not have any such laws and fine amount will be 1000 or 500 or 100 dollars only

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  19. @Rachna
    Even those with good hand writings make prescriptions illegibly.It was some sort of a style,earlier.
    @SG
    Itis difficult to make such a practice in India for long time to come. The problem is private practice and so many of pharmacies.In Govt Hospitals,doctors do not even find time to see patients.
    @BKC yes,true.
    @LathaYou have seen those rare of the species.
    @ Petty
    Thanks, I saw that. I was just wondering.

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  20. I thought bad handwriting was trademark of Docs:)

    and here we now get only computerised prescriptions .. maybe thats the reason for that tooo


    Bikram's

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  21. My impression of doctors' writings - fowl scratchings!! A bad habit which endangers lives. How can they decipher what they have written/prescribed after consultation is over?

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  22. ah, am typing the comment for the third time now!

    U wrote a very useful post, surely its a deadly combination!

    I have read that two types of ppl have a bad handwriting. One, who have a bad character, and the second who think faster than they can write.

    I think, it's the second case for doctors!

    I am following ur blog, u write about current things, and I quite like it.

    tc!

    RESTLESS

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  23. First time here. Great blog.
    My hand writitng is also bad and but till now no mishaps. Hope I can switch to electronic prescriptions soon.

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  24. To my blogger friends
    Great comments.
    There used to be some secrecy in prescriptions earlier.Most of the abbreviations used were in Latin.And doctors made it a point that patients do not read the prescriptions.Sometimes,we use something called placebos,which are not actual medicines,and the patient might get suspicious why the doctor has prescribed him such a medication.It is difficult to explain and convince such things to the patients.This will imply that the doctor is not trusting the patient.
    Most modern hospitals now use the electronic prescriptions.That is a good solution.But in private practice,doctors need to be more careful.A little bit of attention would do.We don't need good handwriting,we need only legible hand writing.
    Thanks again for all the comments.
    @Charakan
    Welcome to the blog.Thanks for the compliment.I am a beginner.Please come as often as you can.

    ReplyDelete

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