Physicians' Handwriting Can Lead to Medication Mistakes

According to an article in the April 1999 issue of Health, the US Food and Drug Administration (FDA) estimates that medication errors lead to 1.3 million patient injuries each year. In a case reported to the FDA, a physician gave a patient a prescription for Isordil to treat the patient's heart disease, but the pharmacist misread the physician's handwriting and thought the prescription was for Plendil, a blood pressure medication. The patient received the wrong medication, had a heart attack, and died a few days later.

Medication errors are becoming increasingly common as more and more medications have similar names (eg, Narcan, Norcuron). One researcher estimates that there are 100,000 such pairs of medication names. Some experts believe that approximately 25% of reported medication errors involve product names that are confused easily. Researchers assert that numerous mistakes could be avoided if physicians wrote legibly or typed the prescription and indicated why the medication is being ordered. This would allow the pharmacist to see the diagnosis and avoid confusion. Researchers also are encouraging patients to check written prescriptions to see if they can read what the prescriptions say and to speak up by asking physicians what medications they are prescribing, what the medications are for, and how often they should take them to prevent medication mistakes.

R Waters, "Could my doctor's handwriting hurt me?" Health 13 (April 1999) 26.