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In the long run, penmanship classes
for doctors won't do much for patient safety
From the January 10, 2001 issue
With the nation's attention now focused on patient safety
issues, television and print journalists frequently cover
stories about medical errors. Often, medication errors caused
by poor physician handwriting are a common theme. While jokes
and cartoons still flourish about illegible prescriptions,
the public is personally familiar with this problem, and it
is no longer considered a joking matter. Recently, national
television networks and wire services have reported a number
of efforts that are underway at hospitals across the country
to bring doctors back to the classroom for courses in basic
penmanship. While we applaud hospitals that seek to improve
handwriting through these courses, we fear that such actions
will achieve only marginal improvement at first and even less
sustained improvement over time.
Handwriting has always been, and will remain, a problem in
medicine. A 1979 study showed that it was difficult to interpret
about half of all physicians' handwritten orders.1
Little has changed since then. In fact, a more recent study
demonstrated that problems with legibility are inherent in
average human writing and that physician penmanship was no
worse than that of non-physicians.2
Therefore, despite isolated pockets of penmanship courses,
it is likely that handwritten orders will continue to pose
a significant risk for misinterpretation. Even orders written
with good penmanship can easily be misinterpreted for several
reasons. It may be misread simply because individual penmanship
styles cause variations in the shapes of characters, or if
the tail or loop of handwritten letters above or below the
order interferes with interpretation. Additionally, even a
legible drug order may be misinterpreted if it closely resembles
another drug name. Illegible orders also cause frequent interruptions
in workflow and waste the valuable time of prescribers, pharmacists,
and nurses if clarification is needed.
It should also be recognized that handwritten prescriptions
represent only one source of problems with order communication.
Although use of preprinted orders and word processing terminals
on units will help, even printed or typed orders can lead
to errors if they present information ambiguously, omit important
information such as the dose or strength, offer too many or
inappropriate drug choices or dose ranges, or use dangerous
symbols and abbreviations. The potential for errors also exists
with oral orders and during nursing and/or pharmacy transcription
of orders. Equally important, many serious adverse drug events
have little to do with illegible handwriting. They occur because
of unrecognized dosing errors, missed allergies, contraindicated
drugs reaching patients, drug interactions, and so on. Improved
penmanship will not help in these cases, but computerized
prescribing technology can.
Much more evidence is needed to be sure that penmanship classes
truly have a sustained effect on medical safety, given the
variability of real-life situations and busy work schedules,
and the effects of fatigue, disruptions, and preoccupation.
Moreover, a course in penmanship should not give the public
or health systems, including the hospital governing body,
managers, and medical staff, a false sense of security. It
must not forestall establishing strategic plans and realistic
timelines to implement computerized methods for prescribing
that have been proven to reduce errors and address most of
the problems mentioned above, including illegible handwriting.3
References: 1) Anonymous. A study
of physicians' handwriting as a time waster. JAMA 1979;
242: 2429-30. 2) Berwick DM, Winickoff DE. The truth about
doctor's handwriting: a prospective study. BMJ 1996;
313: 1657-8. 3) Bates DW, Leape LL, Cullen DJ et al. Effect
of computerized physician order entry and a team intervention
on prevention of serious medication errors. JAMA 1998;280:1311-6.
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