Above: Hastily written prescriptions are often illegible and could even lead to fatalities

With illegibly written prescriptions leading to serious and even fatal errors, the Medical Council of India has amended relevant rules to include and focus on the legibility factor

~By Dr KK Aggarwal

Doctors are known for their bad handwriting. The illegible, hastily written scrawls have often left many patients perplexed trying to decipher the prescriptions. This can be dangerous as it may even lead to fatalities. In the US alone, 100,000 prescription errors occur every year. India does not have any data on prescription errors. A study conducted by the Institute of Medicine of the National Academies of Science in 2006 showed that poor handwriting resulted in more than 7,000 deaths in a year.

Recently, the Allahabad High Court imposed a fine of Rs 5,000 each on three doctors for illegible handwriting in medical records. When the Lucknow bench of the High Court struggled to read the injury remarks of victims in respective medical reports of three criminal cases due to poor handwriting, it reprimanded and penalised the doctors who had written the reports. The bench considered the poor handwriting an “obstruction to court work”.

The Court further directed Principal Secretary (home), Principal Secretary (medical & health) and Director General (medical & health) of the state to ensure that in future, medical reports are prepared in “easy language and legible handwriting”. It also suggested that the reports should be “computer-typed” rather than handwritten to avoid encountering such problems in the future. If the doctors failed to deposit the fine, the amount will be deducted from their salaries, the Court said.

In 2012, the Director General (Medical and Health), UP, had issued a circular directing the doctors to present medical reports in a “readable form”. While referring to the circular, the Court said that the guidelines had been “ignored with impunity”.

Following this judgment, MGM Medical College in Indore, Madhya Pradesh, announced that it will coach students and doctors in improving their handwriting skills.

Why is a doctor’s handwriting so difficult to read? Digitisation has left a tremendous mark on almost all professions, including the medical profession. The medical profession can be said to have two eras—a pre-digital era and a post-digital era.

In the pre-digital era, there were no computers. Teachers used blackboards to teach students. Textbooks were not freely available to all. Hence, medical students relied on hand-written notes of lectures. They had to almost double their writing speed, when taking notes, to keep pace with the teacher. Therefore, they created their own special system of shorthand, which could be understood only by them. Medical words or terminology is sophisticated, difficult and often unique to the profession; hence, even these “distorted” forms of “scribbled” words were understood by the medical students, their teachers and colleagues. This gradually became routine and the handwriting of doctors has now become a major issue, globally, but nowhere as much as in India.

Also, doctors have to see hundreds of patients daily in their limited OPD hours. And, the patient turnout is increasing every day. This further worsens their handwriting, when writing prescriptions, because jotting down all relevant points of medical history and clinical examination takes priority over a “neat” handwriting. So, in the rush of the day, a “legibly” written prescription takes a back seat.

Jokes about doctors’ handwriting abound on the internet and in books, magazines, etc. However, bad handwriting is not just a subject of jokes. Illegible handwritten prescriptions are a common cause of medical errors as well.

Some classic examples of prescription errors are:

• One of my patients with cough and cold was prescribed Laveta tablet to be taken once daily. Bad handwriting led to him taking Caverta tablet instead, which is a viagra group of drug.
• One patient was administered 40 units of insulin when he was to be given only four units (the nurse on duty read U as 0). “U” is often misinterpreted and read as the number “0”, leading to overdoses by many times.

Decimal points are a common source of errors. They are very likely to be misinterpreted.

• A patient received 5 mg tablet Alprazolam (sleeping medicine) instead of .5mg written on a prescription (.5 was read as 5, the decimal point was missed). So, any number less than 1 should be preceded by a zero. Instead of writing .5 mg, it should be written as 0.5 mg.
• Another patient was given 10 mg of tablet Larpose when the intent was to give 1.0 mg (1.0 was misread as 10 mg). Use of a trailing zero after a decimal often causes overdose and should be avoided (write as 1 mg, not 1.0 mg).

Use of abbreviations in prescriptions—for drug names, dosage or admi­nistering instructions—again is a cause for error in drug dispensing due to miscommunication, which can be harmful for the patient. “U” can be mistaken for “0”; “IU” can be mistaken for “IV” (intravenous), with drastic consequences. The terms “unit” and “international unit” should be written instead.

These are but a few examples of prescription errors.

In an attempt to tackle this problem, the Medical Council of India (MCI) amended Regulation 1.5 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 in 2016 to also include the legibility of prescriptions written by doctors in addition to rational prescription and use of drugs.

Regulation 1.5 now reads as follows: “Use of generic names of the drugs – Every physician should prescribe drugs with generic names legibly and preferably in capital letters and he/she shall ensure that there is rational prescription and use of drugs.”

The government then started contemplating electronic health records to avoid such prescription errors. A National eHealth Authority (NeHA) was set up as a regulatory body to oversee digitisation of health records.

In 2016, the Ministry of Health and Family Welfare notified the “Electronic Health Record (EHR) Standards 2016” to introduce a uniform system for creation and maintenance of health records by healthcare providers.

While drug names, doses and abbreviations are legible in electronic format, these are also not free from errors. A single typing error, either when entering the numeric digits for the do­sage and administration or inadvertently typing a wrong alphabet when entering the drug name can have catastrophic results.

Illegibly written medical records can also have adverse medico-legal implications. Prescription errors are avoidable. Electronically written prescriptions seem easier and convenient but may not be free from errors. Many doctors are switching over to the electronic format, but, writing in capital letters, as directed by the MCI, is a cheaper alternative to electronic health records in terms of prescribing drugs. It should be able to keep a check on prescription errors, though it will take some time for doctors to get used to it.