DO YOU SEE WHAT I SEE?
Illegible Handwriting Can Cause Patient Injuries
David O. Hester
I
llegible physician handwriting has
been a long-standing joke in our
culture. However, people are no
longer laughing. Late last year, a Texas
jury found a cardiologist and a
pharmacist culpable in the death of a
patient.
This patient fatality centered on a
prescription the cardiologist wrote for 20
mg of Isordil, to be taken every six
hours. However, the pharmacist filled
the prescription with Plendil, which has
a maximum daily dosage of 10 mg. The
result was a medication overdose that
caused the heart attack the patient
suffered and ultimately died from
several days after taking the Plendil.
The court found that this fatal
medication error occurred because the
pharmacist filled the order with the
wrong medication due to the physician’s
illegible handwritten prescription.
This is a milestone case in that it is
thought to be the first verdict finding a
physician culpable in a patient’s death
based
solely
on
his/her
poor
penmanship. The court found that both
the physician and pharmacy were
equally liable and awarded a total of
$450,000 to the patient’s estate
($225,000 from each defendant).
Poor penmanship in medical
documentation is not unique to
prescription writing. It can be found
throughout handwritten medical records.
How to eliminate the illegibility problem
has been a question many health care
risk managers and patient safety
advocates have grappled with for years.
Efforts to eliminate Mr. Hestor is a Senior
handwriting
problems Risk Management
within medical records is Consultant with
made more difficult in American Physicians
part due to the lack of Assurance Corporation
national data on how
many
patients
are
injured due solely to
poor penmanship.
However, some
organizations such as the Institute of
Medicine (IOM) of the National
Academies, and U.S. Pharmacopeia have
compiled and reported some information
based upon specific studies that address
medical mistakes in general and
specifically medication errors. In a
study released last year, the Institute of
Medicine
reported
that
medical
mistakes, including those caused by
illegible documentation, may cause as
many as 98,000 patient fatalities per year
in this country.
In addition, U.S.
Pharmacopeia’s voluntary medicalerrors reporting program logged 752
reported incidents from November 1998
through October 1999, with 73 of the
752 incidents attributed to illegible
handwriting.
William
Richardson,
Ph.D.,
chairman of the committee that wrote the
IOM’s report states that “it may be part
of human nature to err, but it is also part
of human nature to create solutions.”
Many believe this problem can in part be
solved by the use of electronic systems
for documenting in the patient’s medical
record. These systems require typed
documentation
as
opposed
to
handwritten notes and orders. The same
principles
that
make
typed
documentation more desirable than
handwritten apply to hand-held devices
that are designed to assist practitioners in
communicating
patient
medication
orders to the pharmacist electronically.
As the Texas case shows, physicians
must consistently be aware of the
absolute necessity to communicate
written orders/medical documentation in
a legible manner. Legibility can be
accomplished by not only the use of an
electronic device, but by consistent
effort on the part of the physician to
ensure
that
they
are
clearly
communicating with their intended
audience. This effort includes taking the
additional time necessary to write
clearly. If writing clearly in longhand is
a concern, then print.
Illegible handwriting is in all
probability never going to be completely
eradicated from medical documentation.
However, consistent awareness and
effort to improve legibility on the part of
all healthcare professionals will certainly
go a long way in lessening the
probability of a patient injury or death
caused by poor penmanship. If you are
the author of a medical record entry, or
written order, be sure to double-check
yourself by asking does the recipient of
this communication “see what I see”?