Doctor's Bad Handwriting. It's Time to Talk About It
Kate Gladstone conducts CE seminars for doctors on handwriting. Hospitals pay her for this because patients die because of poor handwriting. It is far less expensive for them to pay Kate than to have to pay after a law suit.
Star Wars: Episode VI – Return of the Jedi Kate and I will be collaborating on a book that will be sold as an e-book over the Internet. It can be sold for a lower price than a paper book. This will be coming up after the first of the year.
I will take my little book, WRITING PRESCRIPTIONS SO THE PHARMACIST WILL LOVE YOU (And Your Patient Will Get The Right Drug In The Right Dose At The Right Time), and will clean it up and edit it. Kate will add her Dos and Don’ts and her handwriting repair primer.
What I am requesting from you is your comments and stories about doctors and their handwriting. Hold nothing back.
You can leave them here as comments.
JP
KATE AND I WILL BE THE JUDGES. WHAT WE CONSIDER TO BE THE COMMENT THAT BEST EXEMPLIFIES THE GROSS DISCOURTEOUSNESS OF PRESCRIPTION WRITERS WILL RECEIVE A PRIZE OF MY LITTLE BOOK,
Writing Precriptions So Your Pharmacist Wil Love You (And Your Patient Will Get The Right Drug In The Right Dose At The Right Time)
A minimum of 20 comments and the game is on.
19 Comments »
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Do: think about what you are writing–is it legible? is it clear? would somebody who does not know me know exactly what I want?
Do: have your name and phone number printed on every rx you write. Carry your blanks with you and eschew the generic hospital blanks.
Do: know exactly the doses of the drugs you prescribe.
Do NOT: prescribe “use as directed” some insurance companies will no longer accept it.
Washington state has made it illegal for prescribers to have bad handwriting. When the law first went into effect, they unfortunately forgot to define ‘illegible’. Now it has been defined, and, to many pharmacists dismay, one of the definitions is “cursive”. Yep, cursive handwriting is illegal on prescriptions in WA. Does that mean that doctors don’t write in cursive? No. What it means is that, by law, every pharmacist has to call the prescriber whenever a cursive script comes along, and document the clarification on the face of the script. What a frickin waste of time! Personally, I think illegible handwriting is like pornography. I can’t define it, but I know it when I see it! Most pharmacists I know no longer call on all of those scripts – after a year of calling on every one, even the perfectly legible cursive scripts, faxing and re-faxing copies of the laws and definitions – it has made no difference at all in the habits of those prescribers who still hand-write scripts. Luckily, a lot have gone to electronic systems that print, fax, or email the scripts, but the worst offenders still write them, and refuse to change (if I had a dollar for every time I heard Dr. T. tell me “that’s not cursive, that’s how I print!” – I would be retiring now)
The best thing to put in a book like that? A list of e-prescribing systems that are recognized and appoved by state boards, which states approve which systems, and a strongly worded suggestion to use them…
My main suggestion is GET TO THEM EARLY.
Start on the teaching floors with the brand new interns and residents and tantalize them with the idea that they will get PAGED LESS if they write their orders clearly & legibly. Don’t depend on someone else to interpret your orders. Oh, and as a bonus, your patients will fare much better!
* Doctors are assigned registration numbers by the DEA. USE THEM!!!!
* SIGN THE PAPER! You’re not the person who is spat on when we can’t fill an unsigned prescription for a CII (True story, and I’ve only worked in pharmacy for a year). Unless you’d like us to send the irrational, smelly, drug seeking cheese-brains *back* to you after you’ve held your nose through dealing with them once, it’s better for *all of us* if we do it right the first time.
* If you can’t be bothered to write your whole name clearly, please at least make sure the first and last initial look like real letters and that your name is printed on the pad you’re using. If I can read J-squiggle B-squiggle and “Dr. James Beam” is printed on the pad, we won’t call Dr. Grey Goose about refills 6 months down the road. But then again, you’ve been writing (or at least printing) your name since kindergarten: it shouldn’t be a challenge some 25+ years later.
* Beware of letters/drugs that look alike. We just had the “is that Robaxin or Biaxin”? discussion today.
*Leave space between the name of the drug and the strength, and the Sig. Fewer clarifications are necessary when everything isn’t crushedintogetherlikeMexicanbuspassengers, to say nothing of leaving space for notes to be added if necessary.
Ihad one doctor that wrote so bad it looked like: Duvoid, 25mg tid. which is actually a reasonable rx. Turnsout it should have been Indocid, 25mg, tid. Even after the doctor called me I couldn’t see the indocid in the writing. If he had just written “for gout” on the damned rx it would have helped….
Pharmacists commenting here have plainly thought long and hard about the handwriting issue. Because I’d like to quote each of them in the book, I hope that everyone who comments here can also privately e-mail me his/her real name (so that the book can attribute comments to professionals by their real names instead of by their nicknames). Please put “Plagakis book” in the subject-line so I spot your message immediately — send it to handwritingrepair@gmail.com .
Something you can tell doctors (because I point it out to doctors) —
Nowadays, hospital accreditation agencies such as JCAHO have taken to evaluating the doctors’ handwritings by pulling random pages of records/Rx’s and showing these to other MDs who don’t know the doctor or the hospital concerned.
JCAHO shows an Rx or record to two of these off-site MDs, asks them “What does this say, and who signed it?” … and, if the evaluating MDs guess wrong or if they don’t agree on the answer to that question, JCAHO can decide that the illegibility forbids renewing the hospital’s accreditation.
Knowing this accreditation fact will often strongly improve an MDs’ commitment/willingness to learn to write legibly
“Sickofstupidpeople” wondered why the state of Washington (Florida had a similar law) decided to classify cursive handwriting as “illegible” for pharmacy purposes. They did this because somebody noticed that prescriptions written purely in cursive had even more serious illegibilities (even more often) than prescriptions handwritten in other ways (such as hand-printed prescriptions, prescriptions in some hybrid style, etc.)
You may or may not know of the research (citation on request) documenting that the clearest rapid handwriters tend to avoid cursive. (Highest-speed highest-legibility handwriters tend to use print-like, not cursive, letter-shapes, and generally avoid joining all their letters: they tend to make only the very easiest joins and to skip the rest. Having just a few joins, and printed letters, tends to get such writing perceived as “print” instead of cursive, even though writing in this style tends to stay legible at higher speeds than cursive writing.)
Therefore, to deal with “no-cursive” rulings as well as the general problems of legibility at speed in cursive, among other things I teach doctors to modify their cursive with a few tips that make it look much more “printed” and legible without loss of speed.
You can see a few of the tips I teach the MDs, with some of the rationale, in the brief video on my web-site at http://www.HandwritingRepair.info or http://www.HandwritingThatWorks.com .
The modifications allow such a style to work in situations that forbid cursive, such as Washington/Florida prescriptions or “please print” forms in any state. Since I have taught classes in Florida (which has a “no-cursive-Rx” law, too) I know for a fact that prescriptions written this way don’t get “called back” to the prescriber.
Thanks also for mentioning e-prescribing. Despite the importance and usefulness of this technology, unfortunately it creates some new problems of its own (which will probably keep it from becoming the one-and-only prescription method).
Jim Plagakis has already described various e-prescribing problems in his existing (paper) version of WRITING PRESCRIPTIONS SO THE PHARMACIST WILL LOVE YOU.
Other problems with e-prescribing include:
/1/ the fact that different states approve different e-prescribing systems, and we therefore don’t yet have a nationally approved system: this deters a lot of hospitals from moving to e-prescribing
and
/2/ e-prescribing systems depend on electric power … so, even when a hospital moves 100% to e-prescribing, what happens when a hurricane takes out the generator?
Lose your electricity, and clear handwriting matters again until you get the power back — so even a hospital that has gone 100% to e-prescribing may need the doctors to learn to handwrite clearly as a sort of “backup.
In some of the hospitals that hire me — including hospitals on the road to 100% computerization, or already there — the hospitals send people from the emergency medicine team to take my class: on the assumption that the next disaster could take out the generator. One Florida hospital even had me visit right at the tail-end of Hurricane Katrina: literally the minute they got their e-prescribing back up, because they wanted something ready the next time the e-prescribing goes down.
To “Frantic Pharmacist” –
I entirely agree with your suggestion to “GET TO THEM EARLY …
Start on the teaching floors with the brand new interns and residents and tantalize them with the idea that they will get PAGED LESS if they write their orders clearly & legibly.” Whenever I visit a hospital, I ask them to make sure that as many as possible of the new interns/residents attend the classes, along with the practitioners who have already earned a reputation for medi-scrawl.
And, yes, I point out to ALL doctors (not just the interns and residents) that writing legibly prevents “pager-itis” because pharmacists won’t have to page them _ad_nauseam_ for translations of the latest scribble!
Thanks, too, to “Becky the Techie” for pointing out the importance of the DEA registration number. To her words on the DEA number, I can only add: the MD needs to write legibly for this or any number! (Sloppy numbers have even worse consequences than sloppy letters, because you can sometimes deduce the correct letter by guesswork but you can never deduce the correct number by guesswork.)
Becky’s other comments (e.g., on signatures) also definitely deserve MDs’ attention (I would like to see them engraved in gold, hung on medical-school walls , and added as a footnote to the Hippocratic Oath. Any presidential candidate who puts that in his platform will probably have my vote.)
To “Carol” –
I definitely want to use your “Duvoid/Indocid” story — not just in the book, but in my presentation to doctors (I like to include actual incidents of handwriting-related Rx problems.) So I hope you’ll e-mail me and give your name (and put “Jim Plagakis book” in the subject-line as mentioned above).
Of course, even if the doctor had written “for gout” on the Rx, it might not have helped … I have seen handwriting so bad that the word “gout” actually could have looked like “urine” or “bladder” or “retention” in the same handwriting!
Reading Jim’s existing book on Rx writing, I’ve noticed that the book’s existing messages from pharmacists use Internet nicknames rather than actual names. So don’t bother sending the actual names if you don’t care to, and the new stories can appear in the book with nicknames just as the older stories did.
Honestly with e-prescribing gaining more acceptance I think generally hand written prescriptions are going to be heading the way of the past very soon. While I think it would generally be beneficial to teach docs the mechanics behind handwritten prescriptions, it will be not needed as much as how to properly form a e-prescription. I’m more worried about the 60 year old doctor using such a program. So often I will receive a prescription that says ‘Lisinopril 20mg (take two at bedtime)’ and then below in the Inst field see ‘take 10mg by mouth daily’. Often that ‘(take two at bedtime)’ is added automatically and even more often the doc will ignore that completely in place of instructions.
Perhaps an equally beneficial guide would be how to properly use e-prescribing and learning to double check. Yes it is a pain in the ass to receive a script and not be able to read, but 9 times outta 10 you can talk to a nurse and they can clarify it for you. It’s a bigger deal when you receive a completely wrong dosage and directions in which it takes two and sometimes three contacts with the doctor themselves to rectify the situation. That is the more inherently dangerous of the two.
I look forward to judging the contest with Jim. Will the winner get the existing edition of the book (written by Jim alone) or the edition that Jim and I have in progress at this point (slated for an early 2009 appearance — probably January)?
Also, I’d like to suggest another possibility. When pharmacists tell about problem prescriptions, they might still also have the actual prescriptions themselves to show for it.
Jim, what about inviting people to not just send in “prescription stories,” but also e-mail you pictures of the worst prescriptions they ever got?
Then you could pick out the very worst one — post its picture on your web-site — and invite readers to try and decipher it. Send one copy of your book to the first reader to “translate” that prescription correctly — send another copy of your book to whatever reader had sent you that prescription in the first place.
If you really want to get attention for the handwriting issue (and for this web-site and the other important issues it covers), how about repeating these contests annually?
Put the contest results onto your web-site on January 12th (National Pharmacists’ Day) or on January 23rd (National Handwriting Day) each year —
on the same date, announce the start of next year’s contest —
and put each year’s worst-ever prescription story and picture into a “Prescription Hall of Shame” somewhere on this web-site.
(Just like the Hall of Fame for baseball, the Hall of Shame for prescriptions would add new material each year: “Hall of Shame, 2008 — Hall of Shame, 2009″ — and so on. And — just like baseball — the world of bad prescribing won’t run out of candidates for the “honor” any time soon. MVP = Most Venomous Prescription, anyone?)
A bit earlier, I mentioned National Handwriting Day (January 23 — John Hancock’s birthday). If all goes well, I would like to time the release of the book’s new edition for that date.
Believe it or not, the above date has some real observance as a focus of efforts to improve the handwriting of doctors (and other people). Every year on the Saturday closest to National Handwriting Day, Portland State University provides a free 3-hour handwriting improvement “crash course” for literally anyone who wants to attend — see http://www.cep.pdx.edu/pdf/NatHandDayFLY.pdf or call the University at 800-547-8887 and ask the operator for extension 4891.
The instructors giving this course usually get 200 – 400 people (at 9:00 on a Saturday morning!) and fortunately they always get a high number of doctors. (Some of the doctors have seen ads in the local paper or on the University’s Internet site about handwriting improvement — other doctors go because their supervisors strongly suggested it.) Although anyone can theoretically just “walk in” to take the course, people who haven’t reserved their free seats in advance often get closed out due to limited space (“only” 400 people fit in the university ballroom where the course meets).
I have seen the “before and after” writings of doctors who attended that free course — amazing and gratifying improvements, not just right after the course but years after they took it
So if you work in that part of the country, and you have a “favorite” doctor whose prescriptions could use a scribal tune-up, you could do worse than tell him or her about this upcoming event.
The only drawbacks —
/1/ they do this free course only once a year
and
/2/ it doesn’t offer Continuing Medical Education credit because the general public also attends.
(Let me know if anyone thinks they could interest a hospital in those handwriting courses that do offer CME credit.)
I agree with “Phathead” on the growing prevalence of e-prescribing and the importance of double-checking ANY form of prescription: whether handwritten, called in, computerized, or done by mental telepathy if we ever get that far.
The current edition of Jim’s book already has material on e-prescribing (including coverage of the problems that can arise when people don’t check for accuracy but just push buttons). — our forthcoming expanded revision will add more material on e-prescribing and the concerns it raises.
The growing acceptance of e-prescribing, I have to say, has not stopped hospitals from worrying about how the doctors write. Quite a few of the hospitals that ask me for handwriting classes tell me something like this: “Kate, we first heard about you 5 or 10 years ago but we were going all-electronic at that time. Now our computer system is in, and theoretically we should be ’100% computerized,’ but we find that the doctors are still writing some things by hand and they are not writing them legibly.”
As an earlier comment mentioned, this can happen in emergency situations — it can also happen when the computer network goes temporarily “down” for any significant length of time. (I’ve never heard of an “all electronic” hospital where the computer network or other system used for e-prescribing never, ever, went down.)
It can also happen at other times, because the doctors who write illegible prescriptions also write other workplace paperwork that may not get into the electronic “data stream.” Now, as pharmacists you probably don’t know or care if the same guy who scribbles on a prescription also scribbles illegible Post-It memos and slaps them onto another doctor’s office door or onto the wall of the nurse’s station … but sometimes the same doctor who has the latest super-duper several-thousand-dollar computer will also have a fax machine and will use it to fax you illegibly.
(If the computers and/or handheld electronics have gone down that day but the fax machines still work, a hospital doctor may fax the hospital pharmacist a handwritten memo rather than wait who-knows-how-long for the electronics to come back up.)
And I definitely share “Phathead’s” worries about e-prescribing done by inattentive or under-informed doctors. (We all sometimes press the wrong buttons — we don’t always notice in time that we have done so.) “Phathead’s” story about self-contradictory e-prescriptions ( such as “Lisinopril 20mg — take two at bedtime — take 10g by mouth daily”) doesn’t even tell us the worst of it: Jim’s book has a story about an e-prescriber who hit a few wrong buttons and turned a quantity of 14 pills into a quantity of 14,000 pills. (Imagine if this had happened with Vicodin and a drug-seeker patient … )
Therefore, I would very much like the book to include the details that “Phathead” suggests: “how to properly use e-prescribing and learning to double check.” As I said, the book already includes some information on this, and the revision would include more. But to make the coverage as detailed and helpful as possible, I would like to include pharmacists’ own pointers on specific ways of avoiding errors when e-prescribing.
Probably “Phathead” and others here have a lot of expertise on e-prescribing issues, so I hope that Jim can see his way to specifically inviting their comments/tips/personal experiences on this matter as well. I would very much like our book to include more e-prescription “horror stories” along with handwritten prescription “horror stories.”
I think another thing that needs to be addressed is that over the past year we’ll receive a prescription for Tadalafil 10mg UUD or Ezetimibe 10mg QD. Both times the pharmacist and I saw that for the first time we were stumped at first. Of course we now know that they are Cialis and Zetia, but at that point we didn’t really know the generic names of those two. Actually if you think about it can you really name the generic names to Avapro or Lescol or Seroquel or Humira off the top of the head? Better yet would you know what it is if you received a script for Fluvastatin? Tack on sloppy hand writing, and you really have a mind bender on your hands.
I am not sure if this is due to the prevalence of PDAs and/or other quick reference guides, but it has become a minor annoyance with us. I’m not saying we should be getting scripts for Hydrodiuril (that, to me, is on par with spelling Hydrochlorothiazide) but for drugs that are still branded it would be greatly beneficial if they referred to them as their common name.
When trihexphenydil was dispensed in place of Estrace in 1996, the issue of illegibility became personal. The pharmacy chain, “experiencing growing pains,” in lieu of staffing a cashier and a technician for 250 rx’s a day, settled the matter with $1800.00 cash in the basement of the store.
The district manager then told the pharmacist to “take an extra minute for each script to ensure accuracy,” without authorizing the new hours of operation needed to perform an additional 250 minutes a day.
Wow! One may ask, “how does such an error occur?” The answer is found in associative familiarity.
Nature and choice cause us to rely on familiar templates, and connection of those templates, as a matter of efficient function. Language is the perfect example. The combinations of letters, cursive, printed, capitalized, or other, replicate recognizable blocks, words. You know the rest.
How many times have we “read” misspelled words without recognizing the error? Our associative familiarity allows us to interject the familiar intent of the language, or see the intended correctness through the familiar structure; sometimes without pause.
With each written prescription, the prescriber offers language she BELIEVES is clear, and legible. Clarity, like legibility, is subjective, and not perceived identically by all.
Similarly, when the pharmacist dispenses a prescription that is in error, one can only rightfully state that he BELIEVED it to be correct. We’re paid to KNOW, and follow up as necessary for therapeutic benefit and safety. Ultimately, any dispensing error blamed on illegibility likely relied on an incorrect answer to a question raised.
Although patients needlessly suffer by the mis-fills and mis-directives RELATED to penmanship, the harm that occurs with mis-fills will only be reduced when we pharmacists, the last line of pharmaceutical integrity, admit and correct our fault.
As for the clear error above, the patient was a loyal patient on Prozac, Mellaril, and Haldol. She dropped off a script during dinner rush. The well-seasoned technician pulled the generic for what she believed was written as Artane. The pharmacist painfully read Artane with an influential bottle of trihex in the basket, KNEW it was appropriate medication, and wrongfully BELIEVED his interpretation was the true intent of the writer.
“Freddie Mac” — your example deserves major attention. It will definitely get a prominent place in the book!
This blog-site desperately deserves a “Hall of Shame for Perilous Problem Prescriptions,” just so that the one you cited can feature there.
The need to proofread e-prescriptions cannot be stressed enough. About a year ago we received an e-prescription for Serax.
Not having seen a script for that in ages, we first indicated to the patient we didn’t have it in stock, and then questioned her on why it was prescribed. From her answer we quickly realized the RX was supposed to be for Septra, and the doctor had simply gone down one too far in the drop-down menu to select the drug, then transmitted it off to the pharmacy. So, this prescription was completely legible and clear, it was just completely wrong. We also have a lot of trouble with prescribers not knowing how to change things that are pre-programmed into the RX, so we’ll see one set of directions on the RX and then a ‘comment’ line that reads something totally different. We are then obligated to clarify this, of course. The drug, strength and route should be clear on the template, but make the prescriber do a little work to enter exact directions and comments if needed.
Frantic: We see the exact same thing. I would think an easy fix would be to have the doc or nurse actually type in the drug/directions instead of using drop down menus. They could use a format similar to what we are using to post comments on this blog. Sure there would probably be some spelling errors, but it would prevent that exact problem with a minimal change in the programming.
That being said we picked up a rumor that later this week the largest hospital in the city will be moving exclusively to e-prescribing in under a year. No more hand written scripts from them.
Something else I noticed today: liquid/gel ink pens leave a very clean, crisp line… when they have time to dry properly. On a glossy script sheet, they may dry beaded, like oil on top of water, or smear.
As a pharmacist from New Zealand (and involved in teaching Med Students how to write prescriptions here) I’m really interested in this input! Two of my big things I’ve been marking students on have been trying to change numbers, rather than re-writing them – BAD NEWS. Also the use of excessive puncutation – commmas, brackets, semi-colons all over the place and you’ve got a recipe for disaster. Unlike someone above I encourage all prescriptions to be written generically (different funding issues here) except where there can be no substitution. Will follow these comments with interest! (My favourite near miss so far is a prescription for co-trimoxazole suspension with a dose in mg that refered only to the trimethoprim component. I called the Dr – as dose seemed high when read as the combination mg dose, and he said ‘of course it’s the trimethoprim component I’m refering to’ uh no Dr, actually that was not clear at all, hence the phone call!)
I, too, see a lot of written-over numbers from MDs!
Feel free to use anything on my site to help your MDs with handwriting.
May I see some of your own teaching materials for doctors? We might help each other improve our materials.
Also, I’d willingly plan a trip to New Zealand to work with hospitals and doctors there. (I’ve worked in Canada and the USA, but so far my Canada handwriting work has not involved doctors.)
I look forward to judging the contest with Jim. Will the winner get the existing edition of the book (written by Jim alone) or the edition that Jim and I have in progress at this point (slated for an early 2009 appearance — probably January)?
Also, I’d like to suggest another possibility. When pharmacists tell about problem prescriptions, they might still also have the actual prescriptions themselves to show for it.
Jim, what about inviting people to not just send in “prescription stories,” but also e-mail you pictures of the worst prescriptions they ever got?
Then you could pick out the very worst one — post its picture on your web-site — and invite readers to try and decipher it. Send one copy of your book to the first reader to “translate” that prescription correctly — send another copy of your book to whatever reader had sent you that prescription in the first place.
If you really want to get attention for the handwriting issue (and for this web-site and the other important issues it covers), how about repeating these contests annually?
Put the contest results onto your web-site on January 12th (National Pharmacists’ Day) or on January 23rd (National Handwriting Day) each year —
on the same date, announce the start of next year’s contest —
and put each year’s worst-ever prescription story and picture into a “Prescription Hall of Shame” somewhere on this web-site.
(Just like the Hall of Fame for baseball, the Hall of Shame for prescriptions would add new material each year: “Hall of Shame, 2008 — Hall of Shame, 2009″ — and so on. And — just like baseball — the world of bad prescribing won’t run out of candidates for the “honor” any time soon. MVP = Most Venomous Prescription, anyone?)
A bit earlier, I mentioned National Handwriting Day (January 23 — John Hancock’s birthday). If all goes well, I would like to time the release of the book’s new edition for that date.
Believe it or not, the above date has some real observance as a focus of efforts to improve the handwriting of doctors (and other people). Every year on the Saturday closest to National Handwriting Day, Portland State University provides a free 3-hour handwriting improvement “crash course” for literally anyone who wants to attend — see http://www.cep.pdx.edu/pdf/NatHandDayFLY.pdf or call the University at 800-547-8887 and ask the operator for extension 4891.
The instructors giving this course usually get 200 – 400 people (at 9:00 on a Saturday morning!) and fortunately they always get a high number of doctors. (Some of the doctors have seen ads in the local paper or on the University’s Internet site about handwriting improvement — other doctors go because their supervisors strongly suggested it.) Although anyone can theoretically just “walk in” to take the course, people who haven’t reserved their free seats in advance often get closed out due to limited space (“only” 400 people fit in the university ballroom where the course meets).
I have seen the “before and after” writings of doctors who attended that free course — amazing and gratifying improvements, not just right after the course but years after they took it
So if you work in that part of the country, and you have a “favorite” doctor whose prescriptions could use a scribal tune-up, you could do worse than tell him or her about this upcoming event.
The only drawbacks —
/1/ they do this free course only once a year
and
/2/ it doesn’t offer Continuing Medical Education credit because the general public also attends.
(Let me know if anyone thinks they could interest a hospital in those handwriting courses that do offer CME credit.)