Monday, December 23, 2013

Poor Handwriting Leads to Patient Death

If you haven't read the article about the culpability in the case of a woman who died as the result of a prescription error, you SHOULD. Here is a LINK to the article.

This story is a horrible tragedy for the victim and family. My heart aches for them because this was preventable on every level.

I disagree, however, with the outcome:

The jury deliberated for two days before finding Dr. F negligent. The jury awarded the family a total of $380,000: $250,000 for Mrs. D's pain and suffering, $110,000 for loss of companionship, and $20,000 for funeral expenses. The jury, however, also determined that the hospital was 90% at fault and Dr. F was only 10% at fault.

What I disagree with is that Dr. F is considered "10% at fault."

This is an OUTRAGE. 

NONE of this would have happened if the doctor had been careful in the beginning. His carelessness cost this lady her life. Ten percent at fault? Really? 

I check prescriptions EVERY day written by careless doctors. Doctors who can't take an extra thirty seconds to make their prescriptions legible. Doctors who write two, three, four, or more prescriptions on one standard size prescription pad like they're having a paper shortage, doctors that misspell, doctors who get the dose wrong, the strength wrong, the instructions wrong.

I've talked to doctors and their staff about their piss-poor handwriting skills. I've asked them to slow down. The response is always the same: Indifference. They treat me like I'm the one with the problem.

Here's some examples from JUST THE PAST WEEK:

This isn't hand written, but it's awkward. If we translated it as written, it would read "Take 1/2 to 1 as needed at night before going to bed by mouth."

Pharmacists deal with this crap every day.

Take a look at this one:

Chew one drop in both eyes? How do you do that?

Ok, enough of the silly stuff. Here's something really serious:

This script was presented to ME. I took the photograph. Six prescriptions were written on two pieces of paper. They were obviously written in a hurry. The script above asks for Isosorbide Mononitrate ER 300mg. 

300mg would kill the patient.

The standard dose is 30mg or 60mg.

This was careless. I caught it immediately. I know I'm not special. I'm certain 99.999% of pharmacists would catch it. But then you have a story like this MPR article. And the question prevalent in my mind is this: Why is the prescriber only 10% responsible for writing a "safe" prescription? Are doctors allowed to write any damn thing they want and it all (or 90% anyway) falls on the pharmacy to catch the errors? 

That's ridiculous! 

If you're a doctor, PA, nurse, or prescriber of medication, please, please, PLEASE slow down. Don't think you can write anything you want and let the pharmacy figure it out. If your handwriting is sloppy, clean it up or get someone else to write it for you. Do you want to live with yourself knowing you killed a patient with your sloppiness? 

Can you live with yourself even if you're only "10%" responsible? 

Think about it.


Anonymous said...

The last script is for Isosorbide monoNITRATE ER, not monohydrate. Apparently, blogging pharmacists can make mistakes too.

Anonymous said...

He said "mononitrate"

Anonymous said...

It's stuff like this that keeps me up at night.

Anonymous said...

The same goes for nurses or staff that leave prescriptions on voice mail and feel that it is necessary to rattle off the info in record time. There is one area nurse that doesn't even take a breath while giving the entire rx. And please, while you're at it, spell the difficult names and don't just say you are from Dr. Smith's office. We have 5 Dr. Smiths in a 3 mile radius of our store.

pharmaciststeve said...

I temped at a big box store one time and I complained that the IVR was "breaking up" when messages was being replayed... The staff was quick to tell me that the person from DR X's office calls in ALL THE RXS and she STUTTERS ! I quickly came to the conclusion that Dr. X was a IDIOT !

Anonymous said...

I got liver failure from a similar mistake (dose out by an extra 0). Took two days (four doses) for a nurse at the hospital to pick it up.
If I went and sued the hospital, it would be the nurses who were blamed, never the doctor.

Sabrina Craig said...

I think the handwriting can be tolerated, as long as they could still be identified and understood by the pharmacist. However, if the error lies on the instructions and dosage, then the doctor should be held liable to the consequences of that mistake. Some people are not quite familiar to the medical jargons and right dosage, that’s why doctors have to be careful on giving prescriptions.

Sabrina Craig @ Medical Attorney

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