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.
For example, Franklin et al (2014) note that in England the Electronic Prescription Service (EPS) was introduced in 2005, beginning with the EPS Release 1 (EPSR1) phase – designed to test the infrastructure – and followed by EPSR2 in July 2009. In their study of 15 UK community pharmacies, Franklin et al (2014) reported that 885 (5.4%) of 16 357 items had a labelling error (incorrect information printed on the dispensing label); 222 (1.4%) had a content error (the wrong product was dispensed); and 2225 (13.6%) had an enhancement made by the community pharmacy staff. Of 3733 EPSR2 items, an EPSR2-specific intervention was made for a further 817 (21.9%) to amend the prescriber's directions. One example of a labelling error was ‘Sulfasalzine 500 mg enteric coated tablets prescribed as ‘three to be taken twice daily’ labelled as ‘take three daily’ (Franklin et al, 2014).
Zheng et al (2020) – citing the World Health Organisation's estimate of the annual global cost of medication errors at US $42billion, and that poor patient understanding of prescription labels can increase medication errors – undertook a retrospective observational analysis of 529 990 e-prescription directions processed at a mail order pharmacy in the United States. They concluded that while pharmacy staff make time-consuming attempts to transcribe patient directions to make them accurate, complete, and easier to read, almost one tenth of directions on prescription labels ‘still had quality issues that may confuse patients when they are deciding how to take their medication. If misinterpreted by patients, these issues may pose a significant safety risk and concern’ (Zheng et al, 2020).
‘Avoidable drug errors may contribute to around 22 300 deaths per year’
The quality of the initial prescription influences subsequent outcomes, with Sam et al (2019) reporting error rates of around 7–10% among prescriptions written by newly qualified clinicians, with more senior doctors having an error rate of around 5%. Further, with prescribing errors most likely to cause moderate or severe harm to patients, and with 66 million of an estimated 237 million medication errors that occur annually in England, being potentially clinically significant, avoidable drug errors may contribute to around 22 300 deaths per year (Sam et al, 2019). To help meet these challenges, Sam et al (2019) developed an online tool – the prescribing very short answer (VSA) question format – to facilitate robust assessment of prescribing skills and medication management. The prescribing VSA aims to improve both the validity of assessment of prescribing skills and enhance the learning behaviour of prescribing among undergraduates.
Other areas where useful interventions can be made include that of critical care, where, for example, Bourne et al (2018) evaluated the views of expert UK critical care pharmacists on the combination of resources they thought would reduce medication errors. They found that ‘[b]ased on the routine availability of these combined resources, units with high resources enabled clinical pharmacists to focus their medication review skills on making clinically significant medicines optimisations, rather than on errors’ (Bourne et al, 2018).
Human error is part of being human, and medical error will always be with us to some extent. However, an awareness by all healthcare workers that small improvements – for example, legible handwriting, concision, attention to detail – can fuel big improvements is a responsibility that cannot be ignored … especially as it is almost certain that at one time or another we will all be patients.