References

Bourne RS, Shulman R, Jennings JK. Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation. Int J Pharm Pract. 2018; 26:534-540 https://doi.org/10.1111/ijpp.12430

Franklin BD, Reynolds M, Sadler S The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study. BMJ Qual Saf. 2014; 23:629-638 https://doi.org/10.1136/bmjqs-2013-002776

Look and Learn. Brief history of Look and Learn. Date unknown. https://www.lookandlearn.com/history/index.php (accessed 12 August 2020)

Sam AH, Fung CY, Wilson RK Using prescribing very short answer questions to identify sources of medication errors: a prospective study in two UK medical schools. BMJ Open. 2019; 9 https://doi.org/10.1136/bmjopen-2018-028863

Velo GP, Minuz P. Medication errors: prescribing faults and prescription errors. Br J Clin Pharmacol. 2009; 67:(6)624-628 https://doi.org/10.1111/j.1365-2125.2009.03425.x

Zheng Y, Jiang Y, Dorsch MP Work effort, readability and quality of pharmacy transcription of patient directions from electronic prescriptions: a retrospective observational cohort analysis. BMJ Qual Saf. 2020; 0:1-9 https://doi.org/10.1136/bmjqs-2019-010405

Handwriting and medication errors

02 September 2020
Volume 2 · Issue 9

Abstract

This month, George Winter takes a look at how poor handwriting by prescribers can lead to medical error – examining the care healthcare workers must continually take to ensure patient safety

In 1964 the children's magazine Look and Learn held its first UK National Handwriting Competition, attracting some 250 000 entries (Look and Learn, date unknown). My primary school entered, and I won a £20 book token for finishing third in my age group. That long-forgotten Walter de la Mare poem, painstakingly scripted in italic with my Osmiroid fountain pen, marked the apogee of my calligraphic proficiency. Today, the inky deposits in my notebook, among which identifiable letters occasionally lurk, passes for handwriting.

Fortunately, I'm not a pharmacist because inaccurate and illegible handwriting, abbreviations, or incomplete prescriptions, ‘for example by omitting the total volume of solvent and duration of a drug infusion, can lead to misinterpretation by healthcare personnel. This can result in errors in drug dispensing and administration’ (Velo and Munoz, 2009). But even if inaccurate and illegible handwriting on medicine containers is replaced by printed instructions to patients, misunderstandings can occur, and at a time when COVID-19 regulations limit pharmacist-patient contact, the accuracy and concision of directions on prescription labels is especially important.

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