It has been a common notion that most of the doctors have dreadful, illegible handwriting. Physician’s illegible hand writing is not associated to one particular region (Ghana) or country but it is world wide or global phenomenon and has been one of the most important contributing factors to the medical errors. Paulina Duodowa (a senior nurse, at the Korle bu teaching hospital) said ‘’ it’s a major problem perhaps not to us the nursesm but it’s a danger to patients as we found it difficult to make meaning out of the prescription.

 

A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. A prescription error as a result of poor or illegible handwriting has been noted to be one of the major causes of medication errors.

The significant of this problem are far reaching and they affect the safety and quality of the health care system. It can harm patients, lead to poor performance of nurses and the support staff, administration of incorrect drugs and doses, improper treatment schedules, and probably the legal perspective.

 

The most interesting aspect of this was the number of people affected by it. The report – ‘To Err is Human’ – by the Institute of Medicine (IoM) states that, medical errors cause at least an estimated 44,000 preventable deaths annually in the United States of America alone.1 Anecdotal evidence and personal experience lead me to believe that the situation in Ghana is far worse.

Medical officers, irrespective of the type of practice, specialty, and country of origin seem to be having this trouble. However, male doctors seem to exhibit the practice of illegible and far worse handwriting than their female counterparts 2, 3 and the senior doctor’s handwritings are more illegible than their junior colleagues and students5.

 

Illegible handwriting causes loss of information and prevents better care for patients. A patient attest to this and said, ‘’I can hardly make meaning in the prescription given me to buy and when I got to the pharmacy, the pharmacist asked me to go back to the doctor for a new order because he too cannot see the writings clearly’’. As a biomedical scientist, I interviewed a number of patients and the conclusion drawn was “A doctor’s handwriting can mean the difference between life and death for patients”. As Mahatma Gandhi said, ‘good handwriting is an asset’4.

From the patient’s perspective, illegible handwriting can delay treatment and lead to unnecessary tests and inappropriate doses which, in turn, can result in discomfort and death13. Illegible handwriting in medical records can have adverse medico-legal implications. Stephens notes that ‘few admissions look more damaging in testimony than physicians admitting they cannot read their own handwriting. Sloppy handwriting can be interpreted by the jury as sloppy care’.7

In a study conducted in Nigeria (“Prescription writing in public and private hospitals in Benin City, Nigeria: The effects of an educational intervention”) to determine how far prescriptions meet accepted standards, 1,197 prescriptions were collected retrospectively from 40 doctors (public and private hospitals). Only 20% of prescriptions were clearly legible.Through face-to-face education with impact evaluation 4 to 6 weeks. Impact evaluation result however proved that handwriting worsened!. Most prescription were illegible ; (80%), which is an obvious threat to quality drug dispensary and just mere educational reforms could not rectify it! A similar study involving a total of 31 medical doctors in Nigeria found illegibility as part of errors comprising 1,388 (52.18%) and omissions 1,221(45.90%).

 

According to Pharmacy Times, errors occur at a rate of 4 per day in a pharmacy filling 250 prescriptions daily, which amounts to an estimated 51.5 million errors out of 3 billion prescriptions filled annually nationwide.

The Institute of Medicine (IOM ) again noted that errors involving prescription medications kill up to 7,000 Americans a year attributable to sloughy handwriting, and that the financial costs of drug-related morbidity and mortality may run nearly $77 billion a year1. Now, take some time to digest this information and you will realize the urgent need for us to root out handwritten prescriptions!

 

“Sometimes patient roam pharmacies for long periods with their drug prescription form because most times the handwriting cannot be made out. So I tell them to go back to the Dr. who made the request to rewrite the drug” said Pharm Appiah, a community pharmacist

 

The issue of illegible handwritings is becoming a serious matter as most pharmacists and, dispensers struggle to make out what drug prescriber write. Some in an attempt to help the patient end up second guessing illegible prescriptions and dispense wrong drugs and dosages.

 

“I have witnessed some situations which have resulted in near fatality and have also heard of some mortality occurring as a result and so I strongly advocate for e-prescriptions” said Pharm Ackah another community pharmacist.

 

In 1999, an American cardiologist caused the death of a 42-year-old patient when his prescription of 20 mg Isordil, an antianginal drug, was misread by the pharmacist as 20 mg Plendil, an antihypertensive drug.5 Poor handwriting undoubtedly contributes to another inconvenient truth: the high incidence of medical errors in Britain, which is estimated to cause the deaths of up to 30 000 people each year.6

The misconceptions and common public opinions,8, 9 is that doctors do scribble as they are not sure about the exact spelling of the medicines and leave it to the pharmacists/nurses decide. However, if this is true, the illegible handwriting should have been selective and should not have been for all the drugs or words.

Others says, doctors are trying to keep the secrecy of the contents of their prescriptions. However, these days, open labelling of the names of the dispensed medicine make this explanation improbable whiles some session of the public thinks doctors have written so much during their college days that the handwriting has deteriorated.

Meanwhile some of the Scientific explanations or hypothesis is that:

  • It is likely that poor handwriting is caused by bad habits acquired while taking lecture notes in medical school and during their college days have not paid enough attention to their handwriting as confirmed by 3 students interviewed and Dr. Yoke, a specialist physician.13,8
  • A few doctors take pride in their illegible handwriting and congratulate those who could read them.
  • The workload may negatively affect documentation accuracy when the charts are handwritten15and the faster a person writes, the less legible the writing is10. For this, Dr. Sireboa (A former Ghana Medical Association president, Greater Accra Region) had indicate that ‘it’s really a problem and as a matter of fact, if a patience cannot read your prescription or writing, then a fellow has compromise ethics’’13

 

Now to suggest solution, we advice among others the following:

All prescription should be in the electronic form13.

As confirm by a pharmacist. “I will recommend e-prescriptions. It makes it far easier” added Pharm Appiah. Some developed countries have already taken the step as, all prescriptions are to be created electronically and this has been backed up with penalties, including fines and imprisonment, for physicians who fail to comply whilst some others have been successful in passing laws requiring electronic prescription.

  • Specify the exact dosage ( such as milligrams) instead of writing one tablet , one ampoule or vial
  • Under graduate and postgraduate medical administrators should take bad handwriting seriously and those taking handwriting lightly should be made to focus on it by virtue of penalties 8 .All medical students are given specific education and training to focus on their handwriting.
  • Conduct educational programs, monitor medication order, and feedback on the handwriting of the doctors 11 .

 

Authors:

Prof George Asare, Promise Edem Nukunu, Prince Opoku Sarpong,Sharon Antah, Mary Nafaye

 

References

 

  1. Winslow EH, Nestor VA, Davidoff SK, Thompson PG, Borum JC. Legibility and completeness of physicians’ handwritten medication orders. Heart Lung 1997 MarApr; 26(2):158-64. http://dx.doi.org/10.1016/S0147-9563(97)90076-5

 

  1. 2. Schneider KA, Murray CW, Shadduck RD, Meyers DG Legibility of doctors’ handwriting

is as good (or bad) as everyone else’s. Qual Saf Health Care. 2006 Dec; 15(6):445. http://dx.doi.org/10.1136/qshc.2006.018911

 

  1. Van Drempt N, McCluskey A, Lannin NA. A review of factors that influence adult handwriting performance. Aust Occup Ther 2011 Oct; 58(5):321-8. doi: 10.1111/j.14401630.2011.00960.x.

 

  1. Gupta AK, Cooper EA, Feldman SR, Fleischer AB Jr, Balkrishnan R. Analysis of factors associated with increased prescription illegibility: results from the National Ambulatory Medical Care Survey, 1990-1998. Am J Manag Care. 2003 Aug; 9(8):548-52.

 

  1. Lyons R, Payne C, McCabe M, Fielder C. Legibility of doctors’ handwriting: quantitative comparative study. BMJ. 1998 Sep 26;317(7162):863-4. http://dx.doi.org/10.1136/bmj.317.7162.863

 

  1. Rodriguez-Vera F, Marin Y, Sanchez A, Borrachero C, Pujol E. Illegible handwriting in

medical records. J R Soc Med 2002; 95(11): 5456 http://dx.doi.org/10.1258/jrsm.95.11.545

 

  1. 8. Jain A, Rastogi P. Doctor, is your writing legible? Indian J Med Ethics. 2009 Jan Mar; 6(1):42.

 

  1. 9. Dunea G. Beastly handwriting . BMJ. 1999 Jul 3; 319(7201):65A. http://dx.doi.org/10.1136/bmj.319.7201.65a Sadananda Naik: Doctor’s Handwriting
  2. Berwick DM, Winickoff DE. The truth about doctors’ handwriting: a prospective study. BMJ. 1996 Dec 21-28; 313(7072):1657-8. http://dx.doi.org/10.1136/bmj.313.7072.1657

 

  1. Winslow EH, Nestor VA, Davidoff SK, Thompson PG, Borum JC. Legibility and completeness of physicians’ handwritten medication orders. Heart Lung 1997 MarApr; 26(2):158-64. http://dx.doi.org/10.1016/S0147-9563(97)90076-5

 

  1. West DW, Levine S, Magram G. Pediatric medication order error rates related to the mode of order transmission. Arch Pediatr Adolesc Med. 1994 Dec; 148(12):1322-26. http://dx.doi.org/10.1001/archpedi.1994.02170120084016

 

  1. https://soundcloud.com/manassehazure-com/doctors-handwriting-edited

 

  1. Sadananda Naik B. Doctor’s Handwriting. MJMS 2016; 1(1): 38-45.

http://ejournal.manipal.edu/mjms/docs/Vol1_Issue1/full/6-Doctors%20Handwriting.pdf

 

  1. https://www.ajol.info/index.php/gmj/article/view/150019