Out-of-the-Box Lawyering

Here's another in a series of ways to decrease medical malpractice suits by decreasing the malpractice — Prevent injuries and deaths due to the illegible prescriptions that physicians write

Have you ever had a prescription where you couldn't even read your own name on the prescription? It's no wonder that patients receive the wrong medications or the wrong dosages from their pharmacists. An article in American Medical News, an American Medical Association publication, describes a case in which a jury found that a patient died because of a physician's illegible prescription and, finding both the physician and the pharmacist liable, rendered an award of $450,000.

The Institute of Safe Medicine Practices in 2000 issued a white paper entitled “A Call to Action: Eliminate Handwritten Prescriptions Within 3 Years!” Well, it's already been four years since the paper was published and not much has been done.

In describing medication errors as “A Compelling Public Health Issue,” the paper cites a 1999 report from the Institute of Medicine and summarizes a portion of the Institute's report:

“The report notes that medication-related errors alone constitute a sizable problem. Errors related to medication orders and prescriptions and to administration of medications kill up to 7,000 Americans annually, both in and out of hospitals. These errors actually cause more deaths each year than workplace injuries, which have long received considerable public scrutiny. One estimate places the annual national cost of drug-related morbidity and mortality in the outpatient setting as high as $76.6 billion.”

(I have a discussion of and citations to the IOM report in an earlier posting.) Of course, not all of the medication-related deaths and injuries are due to illegible prescriptions. But here's what the white paper of the Institute of Safe Medicine Practices says about what it calls “A Handwriting Crisis”:

“One fundamental source of medication errors arises out of the very act of handwriting prescriptions. These errors tend to be failures of communication between the prescriber and the nurse and/or pharmacist who must fill the order. In far too many cases the underlying problem is clinicians' handwriting . . . Many jokes have been made about doctors' sloppy penmanship, but illegibility is no laughing matter. Virtually all of the prescriptions issued each year in the United States are written by hand. Indecipherable or unclear prescriptions result in more than 150 million calls from pharmacists to physicians, asking for clarification, a time-consuming process that could cost the healthcare system billions of dollars a year in wasted time. At the very least, that process can delay the time until patients receive their medications. At worst, a misread order can lead to injury or even death.”

The white paper includes an example in which a physician intended to write a prescription for a diabetes drug, but, instead, a pharmacist, misreading the prescription, gave the patient a blood thinner. The paper adds:

“Virtually all of the 3 billion prescriptions issued each year in the United States are still written by hand.

“An incorrect understanding of the intended drug, dosage, or route or frequency of administration can quite obviously produce a medication error — not to mention an adverse drug event. Given some doctors' hurried scribbles, it may be hard for dispensers to tell whether a zero is preceded by a decimal point or not; if the decimal is misread, the dose ultimately given may be off by an order of magnitude, and the result could be a 10-fold overdose. Poor handwriting can blur critical abbreviations for weights, volumes, or units; mg may be confused with mg [sic], again leading to an overdose. An order marked as ‘qd’ (once a day) might be read as ‘qid’ (4 times a day).”

The paper also includes a table of what it calls “frequently misunderstood” or “hazardous” abbreviations.

A high tech solution

So what's the answer? One answer is for physicians and other health care providers to use computers when prescribing. Those computers can check for potentially lethal incorrect dosages and other dangers such as contraindications due to other medications the patient is receiving. Additionally, the prescriptions will be able to be printed out at hospitals and offices so that there will never be any problems of illegibility.

That's the high-tech solution, and it is being done, although it is being done slowly — very very slowly — and only in a small number of locations.

What about a low-tech solution?

Now, what about a low-tech solution for preventing deaths and injuries due to those illegible prescriptions? Here's the lowest of the low-tech solutions: Florida now requires that prescriptions for medicinal drugs issued by health care practitioners “must be legibly printed or typed.” As an additional safety factor, Florida also requires that the quantity of the drug prescribed must be set forth both in textual and in numeric formats. (The statute is quoted in full below.) (Tennesse has also passed prescription-related legislation.)

Prescription-related bills have been introduced in the Michigan legislature. Both bills have passed the Michigan House and are presently before a Senate committee. House Bill 5328 of 2003 is a broadly-worded bill designed to prevent “prescription medication errors.” House Bill 5549 of 2004 would require that handwritten prescriptions be “legibly printed in a type not smaller than 10 point, written with ink or an indelible pencil.”

The Detroit News, in a June 13 article reporting on Bill 5549, adds:

“Long a source of humor, messy handwriting is now a semi-serious issue. In 2003, the University of Michigan Medical Center began requiring all doctors to complete courses about the dangers of bad handwriting. Nationwide, some hospitals even teach penmanship.”

However, The Detroit News has editorialized against the handwriting requirement. Interestingly, the title of its editorial was “Neat Handwriting Bill for Doctors is Overkill.” Actually, I believe that I think the bill should really be described as “underkill” rather than “overkill,” for, although it does do some good, it only goes a small part of the way toward saving lives. But, at least it is a good start toward physicians not killing their patients, albeit unintentionally.

There is an interesting medical term that fits here. That term is “iatrogenic.” One online dictionary defines the term as “induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.”

Let's hope — and work — so that, one day, there will no longer be any iatrogenically-caused deaths and injuries due to illegible prescriptions.

A personal experience

I was in Amsterdam in 2001 — three years ago — when I took my grandson to a pediatrician's office there. It was a small two-physician office. After the pediatrician examined him, she gave me a prescription. And guess what! She had used her standard desktop PC to print the prescription.

LINKS:

American Medical News article
http://www.ama-assn.org/amednews/2003/08/04/prl20804.htm

Detroit News article
http://www.detnews.com/2004/health/0406/18/d01-181854.htm

Detroit News editorial
http://www.detnews.com/2004/editorial/0406/16/a12-184341.htm

Dictionary definition of iatrogenic
http://www.emedicinehealth.com/dictionary/dictionary.asp

Florida statute
http://www.flsenate.gov/data/session/2003/Senate/bills/billtext/pdf/s2084er.pdf:
Florida statute, Section 456.42, Florida Statutes:
“456.42 Written prescriptions for medicinal drugs. — A written prescription for a medicinal drug issued by a health care practitioner licensed by law to prescribe such drug must be legibly printed or typed so as to be capable of being understood by the pharmacist filling the prescription; must ontain the name of the prescribing practitioner, the name and strength of the drug prescribed, the quantity of the drug prescribed in both textual and numerical formats, and the directions for use of the drug; must be dated with the month written out in textual letters; and must be signed by the prescribing practitioner on the day when issued.”

Institute of Safe Medicine Practices white paper
http://www.ismp.org/msaarticles/WhitepaperPrint.htm

Institute of Medicine report “To Err Is Human: Building a Safer Health System”is discussed, with citations to the report, in this weblog at http//www.outoftheboxlawyering.com/archives/000042.html

Michigan House Bill 5328 (2003) history and legislative analyses
http://www.michiganlegislature.org/mileg.asp?page=getObject&objName=2003-HB-5328

Michigan House Bill 5549(2004) history and legislative analyses
http://www.michiganlegislature.org/mileg.asp?page=getObject&objName=2004-HB-5549

Tennessee statute on prescriptions by podiatrists, dentists, physicians, optometrists, and osteopathic physicians
http://www.state.tn.us/sos/acts/103/pub/pc0678.pdf

Posted by ajlevy at November 22, 2004 1:53 PM