Institute for the Study of
Healthcare Organizations & Transactions


For Doctors’ Scrawl, Handwriting’s on the Wall

Healthcare providers’ compliance behavior is revealed by this headline from another newspaper article, by Rene Sanchez (Washington Post, May 16, 2000). Folklore has it that physicians’ handwriting is notoriously bad, and with the increased importance of prescription medicines in treating diseases of every sort, poor penmanship increases the probability of fatal medication errors.

Even more than handwashing, prescription errors show how adverse medical outcomes can reflect not just the misbehavior of an individual, but rather the complexity of the entire healthcare system. An analysis by the Institute for Safe Medication Practices (ISMP) shows how complex the system actually is.

First, the physician has to write or otherwise order the prescription. 
Then, the prescription must be routed to the pharmacist, who reviews the order and then dispenses the prescription. 
Finally, the prescription has to be administered, by either the patient or a caregiver. 

Both the physician and the pharmacist are responsible for counseling the patient about the prescription, and for monitoring the patient’s progress. Errors can occur at any of these points, but the very first preventable error is miscommunication by the physician through indecipherable handwriting, misplaced or omitted zeros and decimal points, and confusion between metric and apothecary systems. According to the ISMP,

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.
To read the ISMP White paper, "A Call to Action: Eliminate Handwritten Prescriptions Within 3 Years!", Click on

In 1999, a Texas jury awarded a woman $450,000 after her husband died when his pharmacist misread "Plendil" (a medication for high blood pressure), for "Isordil", a medication for heart pain. The jury concluded that his physician’s poor handwriting was responsible for the error. An analysis by the Institute of Medicine’s Committee on Quality of healthcare in America, a unit of the U.S. National Academy of Sciences, concluded that medical errors, including prescription errors caused by poor handwriting, might be partly or wholly responsible for as many as 98,000 deaths per year (L.T. Kohn et al., To Err Is Human: Building a Safer Health System, 1999).

Aware of the impact of medical errors, the American Medical Association has long cautioned physicians to take greater care with their handwriting. One approach to poor physician penmanship has been to send doctors back to school. In a handwriting class at Cedars-Sinai Medical Center in Los Angeles, physicians learn to write in an "italic" style that is highly readable. Indiana University Medical School has added penmanship exercises to its curriculum on quality of care.

Penmanship.gif (407421 bytes)The short-term results of programs like the one at Cedars-Sinai may be positive, but in the long run physicians are only human, and they’re likely to slip back into their old habits of poor handwriting. Click on the image at the left to view a before-and-after example of a penmanship course at Cedars-Sinai Medical Center (The Washington Post National Weekly Edition, June 19, 2000, p. 30). 

For that reason, the ISMP has advocated the use of electronic prescribing tools that computerize the process of ordering prescriptions. A study by Bates et al found that a computerized order-entry program reduced potentially harmful prescription errors by 55% (Journal of the American Medical Association, 280, 1311-1316, 1998). In another study, a computerized system reduced allergic drug reactions and excessive drug dosages in an intensive care unit (Evans et al., New England Journal of Medicine, 338, 232-238, 1998).

Of course, a computerized order-entry system is not just a fancy typewriter. The computer can also check for drug side effects and inappropriate dosages, among other errors. (In the Texas case described above, the pharmacist might have been alerted to the error by the fact that the prescribed amount of drug, 80 milligrams, was 8 times the usual dose of Isordil.) So it is not clear how much of this error reduction was produced by improved "handwriting".

Allscripts, a pharmaceutical benefit management (PBM) firm in Libertyville, Illinois, now offers its clients a Hewlett-Packard handheld computer with "TouchScript" software that allows physicians to order prescriptions by touching the screen. Before processing the prescription, the computer checks the provider’s request for side effects, drug interactions, and insurance coverage. Then the data is transferred wirelessly to a desktop machine in the provider’s office. Other systems link providers directly to pharmacies over the Internet. Of course, the advantages of the new technology bring with it new risks -- in this case the potential threat to patient privacy by having prescription information flowing through cyberspace.

As with handwashing, (Click on Hand Washing by Health Care Providers to read this Hot Topic), the penmanship problem is one that requires systemic change. In order for new technology to improve the management of medications, the provider’s computer system must be able to communicate with the pharmacist’s. In this way, the possibilities for slippage between prescription and labeling can be greatly reduced. But this will require a network that links every provider’s office to every pharmacy. 

Compliance is not just a problem for patients anymore; nor is it just a problem for providers, either. It’s a problem for everyone, up and down, throughout the healthcare system.


John F. Kihlstrom, PhD

Copyright © 2000 Institute for the Study of Healthcare Organizations & Transactions