Illegible handwriting and other prescription errors on prescriptions at National District Hospital, Bloemfontein

Abstract

Background: It is generally accepted that doctors have illegible handwriting. The writer usually knows what is written, but other parties often have problems with reading and interpreting. Aim: The aim of the study was to determine whether illegible doctors' handwriting and other factors that can lead to dispensing errors occur on prescriptions at National District Hospital. Method: In part one the prescriptions of 20 doctors were read by five doctors, nurses and pharmacists to detect who could read it most accurately. In part two, these doctors were asked to write a prescription with an IntelliPen®. Results: From the 300 measurements, 88% of the doctors read the prescriptions correctly, compared with 82% of the nurses and 75% of the pharmacists. A potential fatal error was lorazepam injection 4 mg, which was read as 40 mg (lethal dose) by 20% of healthcare workers (HCWs). With the IntelliPen® only 39% of the prescriptions were readable. Only 65% of prescribers could be identified from their handwriting or the name stamp used. Conclusion: Pharmacists read the prescriptions worst and they are the people who must dispense the prescriptions. Some of the reading mistakes were critical and could be lethal. Many of the prescriptions did not meet the legal requirement for prescriptions.

Prevalence and Types of Prescribing Errors at A Public Tertiary Care Centre in Malaysia

“…As poor handwriting was reported to kill more than 7,000 people annually in the US alone, [14] efforts should be made toward preventing such errors, such as by encouraging the use of free yet user-friendly web-based prescribing tools. [15] ( Table 3) However, the study has several limitations. First, the generalizability of the findings is limited mainly by its single-center design.…”

A new approach of assessing patient safety aspects in routine practice using the example of “doctors handwritten prescriptions”

“…Handwritten medication prescriptions still represent a common practice in hospitals worldwide. Prescription may be illegible as well as incomplete in terms of missing prescriber initials, missing or wrong dosage, missing or wrong frequency, and missing or wrong route of administration (Brits et al, ; Gommans, McIntosh, Bee, & Allan, ; Naik, ; Thirumagal, Ahamedbari, Samaranayake, & Wanigatunge, ). It is generally known that illegible handwriting among doctors is prevalent.…”

“…It is generally known that illegible handwriting among doctors is prevalent. It is also one of the most important factors affecting patient safety and results in adverse clinical outcomes (Brits et al, ; Bruner & Kasdan, n.d.; Michaelson et al, ; Naik, ; Roy, Bhunia, Das, Dhar, & Pal, ; Scanlin, ; Sokol & Hettige, ). Annually, around 7,000 mortalities have been reported due to medication errors, and it is reasonable to assume that this is only the tip of the iceberg (Sheikh, Mateti, Kabekkodu, & Sanal, ).…”

“…Besides doctors who know what is written, nurses or pharmacists for example have to subsequently deal with illegibility and incompleteness of prescriptions when dispensing medication (Brits et al, ). Illegibility and incompleteness are preventable, either by a change of habit on the part of prescribing doctors or through the digitization of the prescription process (Boehringer, Rylander, Dizon, & Peterson, ; Vaughn & Linder, ).…”

An Efficient and Provably-Secure Certificateless Proxy-Signcryption Scheme for Electronic Prescription System

“…Such errors can be fatal. For example, in a study by Brits and Verma [5], it was found that illegible handwriting and other prescription errors on prescriptions resulted in "lorazepam injection 4 mg" being misread as "40 mg (lethal dose) by 20% of [the] healthcare workers. "…”