If handwriting lessons are out, how do you get docs to write legibly?

Here are a few remedies for recalcitrant scribblers

A doctor’s poor handwriting is more than just an amusing stereotype. Too often, a poorly written drug prescription can lead to serious complications for the patient — and even death. Health care risk managers should take steps in their own facilities to reduce the risk of prescription errors from poorly written drug orders, says Robert T. Brodell, MD, head of the dermatology section at Northeastern Ohio University’s College of Medicine in Rootstown. He also is associate clinical professor of dermatology at Case Western University in Cleveland.

Eliminating prescription errors may not be possible, but they can be greatly reduced by implementing a few strategies that compensate for the most common human errors, he says.

"Most doctors will recognize this problem and admit that it can lead to drug errors, but most of them won’t do anything about it without someone prompting them," Brodell tells Healthcare Risk Management. "Unless hospital administration gets involved, it is not likely that much progress will be made in fixing the problem."

Brodell and his colleagues recently addressed the problem of prescription errors when they came across three instances in which pharmacists gave patients the wrong medication. Realizing that the errors could have serious malpractice implications, not to mention the threat to patients’ health, they studied how those errors happened and used that information to improve their prescription practices. With all three of the patients, a check of the original prescriptions showed they were poorly written. The pharmacists did not question the drugs and dosages, even though their interpretation of the written prescription might have raised questions in their minds.

The most obvious solution, Brodell says, is for doctors to write more clearly and carefully. He recommends that physicians take a hard look at their own prescription-writing practices, but of course, classes in remedial penmanship would not go over well with physicians.

"Having some sort of professional teach us to write better would address the root problem, but I think that is pretty much hopeless," he says. "That leaves us with how to accommodate a doctor who has, shall we say, a handwriting disability."

Brodell notes that this can be a politically sensitive issue for risk managers to address. No one likes to hear that everyday practices are faulty and threatening to patients, and people can be especially defensive about their handwriting. It does not help that physicians’ poor handwriting has become such an old joke.

"But if you don’t attack this type of error, how are hospitals going to attack the bigger issue of a whole chart that is illegible?" he asks. "That’s a more complex issue, and the prescription errors seem more amenable to addressing. Once we figure out how to deal with these problems, maybe we can move on to other illegibility problems."

To confirm how serious the problem is, Brodell suggests that risk managers stroll down any hospital unit and look at 10 patient charts. Then go to the pharmacy and look at any 10 prescriptions. Even though the clinical notations may not be exactly within your field of expertise, you should be able to read them. Chances are good that you will consider some totally legible, a large number mostly legible, and some totally illegible.

Pre-printed pads can solve part of problem

Brodell suggests that facilities implement policies that address some of the particular problems encountered with ambiguous prescriptions. These are some of his suggestions:1

Consider pre-printed prescription pads or a computer program.

Pre-printed prescriptions save a lot of time and eliminate many, but not all, errors. Since the drug name is printed on the pad, there is no confusion about that. The pads can be printed for a small cost, and in many cases, the drug manufacturer will provide them at no charge. The pads can be color coded for easier use. Note that some states do not allow typed prescriptions for some controlled substances.

In Brodell’s practice, he uses pre-printed prescription pads stored in each exam room. The pads cover about 150 commonly prescribed medications. There is a drawer full of them in each room, always arranged in the same manner so the doctor can find the one he wants easily. Brodell has the drug manufacturers supply the pads, and he always asks that they be printed on the "ugliest, oddest colors I can find." That helps differentiate the pads from one another so he can access them easily and further reduce the chance of confusing the pads.

"It takes just a split second to find it, pull it, adjust the prescription if necessary, and give it to the patient," he says.

Software heads off drug interactions

Computer programs offer indisputably clear printing, just as pre-printed pads do. But in addition, they can offer the ability to track all the prescriptions for a single patient and detect potential errors before they harm the patient.

Encourage physicians to let someone else do the writing.

If it is clear that a nurse or other assistant can write the prescription much more legibly than the doctor, let that person do the writing and then the doctor can check it for accuracy before signing. Brodell suggests that the designated employee can attend the patient education session and write the appropriate prescriptions as the doctor explains them to the patient.

Urge doctors to print.

Almost everyone prints more clearly than they write in cursive.

Remind staff to use abbreviations and numerals very carefully.

For instance, they always should spell out the word units. When in doubt, spell out the instructions instead of using abbreviations.

The dosage is easily confused on some prescriptions. To minimize errors, do not use trailing zeros, the one that you would place after a decimal point. But do use a leading zero, the one you would place before a decimal point.

So you should write a prescription as 3 cc, not 3.0 cc. If the decimal were overlooked, the dosage could be seen as 30 cc.

And you should write 0.5 cc, not .5 cc. If the decimal were overlooked, the dosage could be read as 5 cc.

Encourage pharmacists and others to question prescriptions.

Malpractice cases often involve tragic errors that could have been prevented if someone had just spoken up. Pharmacists who think the prescription is wrong or nurses who think they are about to administer too much medication should feel free to double-check with the doctor before proceeding.

"Physician handwriting is the genesis of the problem, but there might be other people in the office who see an illegible prescription and let it go by," he explains. "It gets worse if the pharmacist can’t read the prescription but fills it anyway, or if the pharmacist thinks there’s something wrong with the dose and still fills it. Then there can be a problem if the doctor’s office makes the pharmacist uncomfortable when he or she calls to ask about it."

Computers can eliminate many problems

Extensive computerization of the prescription process is one of the most promising solutions to prescription errors, Brodell says. Unfortunately, it is not simple to computerize the process. Brodell notes that he has not seen a computer system he is eager to adopt, but he still thinks computerized prescriptions soon may eliminate most errors.

Brodell has not purchased a computerized system yet because he has not been entirely happy with the ones designed for drug prescriptions. A hospitalwide network that addresses a number of data transfers, including drug prescriptions, might work better than a system designed only for drug prescriptions, he says. Such a solution has been in place at Wishard Memorial Hospital in Indianapolis since 1988, where a network of computer workstations for writing all inpatient orders has reduced errors and saved the hospital $887 per admission.

William Tierney, MD, professor of medicine at the Indiana University School of Medicine and associate director of the Regenstrief Institute for Health Care, both in Indianapolis, described the system in a recent issue of the Journal of the American Medical Association.2 The microcomputers are stationed in all six inpatient wards of the hospital, with three to five workstations in each ward. The computers are tied into the hospital's medical record system as well.

Instead of writing drug prescriptions and other orders by hand, physicians log onto any available workstation and use a series of menus. After each ordering session, the computer prints all the orders and completes requisitions, using the data just entered and data from the patient’s computerized record. Most of the printed orders are then passed on to ancillary services just as a handwritten record is. Drug orders, however, are sent electronically to the satellite or central pharmacy for fulfillment.

System saves money and time

The computerized system was formally studied for 18 months, during which the system was used for 5,219 patients. Physicians and medical students were divided into two groups, with one group using the system and a control group using the manual method of ordering drugs and services. Prescription errors, at least those resulting from unclear prescriptions from the doctor, were practically eliminated in the group using the computerized system.

Additionally, average drug charges for the group using the system were 15.3% lower as a result of the computer system automatically suggesting less expensive alternatives and questioning expensive orders. There also were significant reductions in the average lengths of stay, test charges, bed charges, and total charges.

The savings may have come partially from the fact that the computer system makes physicians aware of the cost of what they are ordering, Tierney says. The patient’s charge for each item is displayed, and menus list the most cost-effective tests for common problems. For tests, the system only provides options that represent reasonable testing intervals, such as three times a week instead of daily.

References

1. Brodell RT, Helms SE, KrishnaRao I, et al. Prescription errors: Legibility and drug name confusion. Arch Fam Med 1997; 6:296-298.

2. Tierney WM, Miller ME, Overhage JM, et al. Physician inpatient order writing on microcomputer workstations. JAMA 1993; 269:379-383.