Handwriting on the wall?
From the July 16,1997 Issue
We recently learned about a case in which the physician,
the pharmacist and the pharmacy are all being sued for damages
as a result of a death. The patient received a prescription
for Isordil® (isosorbide dinitrate) 20 mg q 6 hours.
However, the physician's handwriting was illegible, and the
pharmacist misread the prescription with Plendil® (felodipine).
After taking the medication for a day, the patient suffered
a myocardial infarction and died a few days later. According
to the plaintiffs, reasonable standards of medical and pharmaceutical
care were not provided by the physician, the pharmacist or
Fig. 1. Poorly written prescription for
Isordil seen as Plendil
Plaintiffs' attorneys are beginning to appreciate the systemic
nature of medication errors. In particular, in this case they
recognized that the physician wrote poorly and the indication
was not included on the prescription. The pharmacist was named
in the suit because he did not question the illegible prescription
or the high dose of Plendil (maximum dose 10 mg daily). The
pharmacy itself was also named in the suit because it failed
to incorporate controls that could have prevented the error.
For example, the pharmacy computer did not catch the excessive
Certainly, physicians and pharmacists have been sued in civil
court for errors in the past. However doctors are usually
sued if the wrong medication was due to misdiagnosis while
pharmacists usually bear the brunt of the blame for dispensing
the wrong product. Whatever transpires with this case, it
could set a new standard of practice.