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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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