PHARMACY CONNECTION ARTICLE

Focus on Error Prevention: Illegible Handwriting

Published on: May 1, 2016 pharmacist with prescription

By Ian Stewart B.Sc.Phm., R.Ph.

It is well known that failed communication due to illegible prescriber’s handwriting is a major problem in pharmacy practice. Pharmacists spend an enormous amount of time contacting prescribers to clarify illegible or ambiguous handwritten prescriptions. At a minimum, this process results in a delay in the provision of patient care. At worse, misinterpretation of an illegible prescription may result in the dispensing of an incorrect drug, dosage, frequency or route of administration and can lead to patient morbidity or mortality.

With the availability of electronic prescribing, hand written prescriptions should be a thing of the past. Computerized physician order entry (CPOE) has been shown to prevent errors caused by illegible handwriting1, 2. CPOE systems can also screen prescriptions for potential problems such as drug allergies, inappropriate dose or frequency of administration, contraindications and drug-drug interactions. Computer generated prescriptions also reduces the potential for misinterpretation of the prescriber’s intent due to similarity in drug names and abbreviations.

It was therefore interesting to learn that recent legislation passed in New York State requires all prescriptions issued in New York State to be electronically transmitted, with limited exceptions.
Though the I-STOP (Internet System for Tracking Over-Prescribing) Act was passed by the New York State legislature to help combat the rising rates of prescription drug abuse in New York, the effect would be the discontinuation of handwritten prescriptions.

Though computer generated prescriptions can reduce some types of medication errors, pharmacist must be vigilant as computer entry errors are often seen. Prescribers often make their selection of the drug from a drop down menu. An incorrect selection can result in a drug that is similar, but not therapeutically equivalent to the intended drug entity.

Case:

A forty-six year old patient had been taking diclofenac sodium intermittently for a shoulder injury. The patient attempted to contact his family doctor for a refill of his medication, but was unsuccessful. The patient therefore visited a local walk-in clinic and requested a prescription for diclofenac tablets.

The physician used a CPOE system and selected diclofenac potassium from a list of drugs. The prescription was computer generated and given to the patient who took it to his regular community pharmacy for processing.

The prescription was processed correctly as prescribed and the medication given to the patient. The offer to receive counselling was refused by the patient as he indicated that the medication had been taken previously.

Upon arriving home, the patient opened the vial, noticed the change in tablet appearance and contacted the pharmacy to report that the incorrect medication had been dispensed.

Possible Contributing Factors:

  • The patient visited a new doctor who was likely unfamiliar with the different forms of diclofenac.
  • The physician chose diclofenac from a drop down menu. Diclofenac potassium appears on the list before diclofenac sodium and was therefore selected.
  • The patient’s medication history was not consulted by the pharmacist to identify any change in drug therapy.
    Recommendations:
  • Though computer generated prescriptions can minimize medication errors due to illegible handwriting, be aware that computer entry errors can occur.
  • Always consult the patient’s medication history to identify changes in drug therapy and to detect prescribing and dispensing errors.

Please continue to send reports of medication errors in confidence to Ian Stewart at: [email protected].

Please ensure that all identifying information (e.g. patient name, pharmacy name, healthcare provider name, etc.) are removed before submitting.

REFERENCES

  1. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA.1998;280 :1311– 1316
  2. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc.1999;6 :313– 321
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