Write Drug Names in Capital Letters to Avoid Prescription Errors

Doctors are known to have poor handwriting and they also use abbreviations in their prescriptions. As a result, quite often, prescriptions may be unreadable and it is often said that only chemists could decipher a doctor’s prescription. This is an area that needs to be addressed by doctors as illegible prescriptions may be misread and wrongly dispensed, often with disastrous consequences.

A report ‘Preventing Medication Errors’ from the Institute of Medicine (IOM) published in 2006 said, “In hospitals, errors are common during every step of the medication process—procuring the drug, prescribing it, dispensing it, administering it, and monitoring its impact—but they occur most frequently during the prescribing and administering stages.”

Beneficence and nonmaleficence along with patient autonomy and justice constitute the four guiding tenets of medical ethics. Patients come to us when they are sick and as clinicians, we are trained to use our skills and knowledge to diagnose and treat them. This is the principle of beneficence ‘do good’ complemented by that of ‘nonmaleficence’, i.e., to do no harm.

The fiduciary nature of the doctor-patient relationship places an ethical obligation on the doctor to always put the interests of the patient first.

To reduce prescription errors, the Medical Council of India (MCI) has issued guidelines that require doctors to write in capital letters to that the writing is legible.  

In September 2016, MCI revised its code of ethics notified as Indian Medical Council (Professional Conduct, Etiquette and Ethics) (Amendment) Regulations, 2016 - Part I. this revision required doctors to write the generic names of drugs and in capital letters so that the drugs prescribed could be easily read and dispensed. The notification read as follows: In Chapter 1-B-Duties and responsibilities of the Physician in general, Clause - 1.5 under the heading - Use of Generic names of drugs, the following shall be substituted: “Every physician should prescribe drugs with generic names legibly and preferably in capital letters and he/she shall ensure that there is a rational prescription and use of drugs.”

IMA welcomes the new MCI gazette notification asking doctors to prescribe generic medicine in capital letters but clarifies it further. “Every physician should prescribe drugs with generic names legibly and preferably in capital letters and he/she shall ensure that there is a rational prescription and use of drugs.”

Here are some examples of common prescription errors and how to avoid them.

• Always spell the drug:Always spell the drug if you are giving telephonic instructions. Sound-alike drugs can cause confusion.
• g., the patient received Isoprin IV in place of Isoptin and nearly died.
• g., Amlopress AT/80 mg; a hypertensive called up his family physician who asked him to take amlopress AT but the patient took amlopress 80 mg. After sometime he developed dizziness, flushing, palpitation, nausea and abdominal pain.
• Never write ‘U’ to abbreviate the word ‘units’: Do not write ‘U’ for units when writing prescription. Always write the complete word ‘units’. It may be mistaken as zero. E.g., never write 4U insulin. The patient may be given 40 units of insulin when the doctor meant 4 U (4 units).
• Never write the numeric after a decimal point: The use of a trailing zero after a decimal point when writing prescription may lead to medication errors. E.g., do not write 3.0 mg. There are chances that the patient may get 50 mg; 5.0 mistaken as 50 mg if the decimal point is not seen.
• Always write the numeric 0 before the decimal point: Always add a leading zero when writing dose of a drug, which is <1. Lack of a leading zero may lead to a decimal point being missed. For example, never write .25 mg; instead write 0.25 mg. Otherwise there are chances the patient may take 25 mg in the first instance itself.
• 8-2-8 mistake: The time interval should be written more clearly as 8am2pm8pm. Or, the patient may consider it to be the number of tablets to be taken 8 in the morning, 2 in the afternoon and again 8 at night.

Be ‘ALERT’ when Communicating with Your Patient

Communication forms the basis of doctor-patient relationship and more often than not, it is also at the root of many instances of conflict between the doctor and the patient or the relatives of the patient.

Professional competence is anyway expected from doctors give their medical education and qualifications, but they are also expected to be compassionate towards their patients. Patients expect their doctor to listen to them and be courteous at the same time.

Doctors are governed by regulations formulated by the MCI relating to Professional Conduct, Etiquette and Ethics. While ‘Ethics’ is a subject that is often in the spotlight, Conduct and Etiquette are often ignored paving the way for a deteriorating doctor-patient relationship manifesting as violence, which we often read about in newspapers or watch on TV news reports.

A patient who comes to the doctor is emotionally vulnerable. He/she is going through several emotions such as anger, sadness, anxiety, fear, etc., which may at times manifest as negative behavior. But as doctors, we should always be empathetic to our patients.

It is important to remember that etiquettes and conduct are complementary to the science of modern medicine. I have devised an acronym ‘ALERT’ as a check list for doctors to improve their soft skills.

• Acknowledge the patient by his/her name; this is the first step across the barrier. Introduce yourself or your staff who would be involved in patient care.
• Listen to your patients without interrupting or cutting them short in their narration. Try not to judge them.
• Explain the diagnosis, the proposed line of treat­ment, duration of treatment, etc. to your patients. This forms the basis of ‘informed consent’.
• Revise: Review your instructions or the information given with the patient to make sure that they have been understood correctly. This will help improve compliance to prescribed treatment and patient participation in decision making.
• Thank you: Say thank you to the patient. This is courtesy. He has trusted you with his health needs.

Following this check list will foster a doctor-patient relationship that is based on mutual trust and respect…the need of the hour.

Inform Your Patients before Traveling

The doctor-patient relationship is a sacred relationship. This relationship is initiated when the patient comes to the doctor, who in turn agrees to treat him. This ‘implied contract’ imposes on the doctor a legal duty to exercise due skill and care in providing medical treatment. Once a doctor takes on the care of the patient, he also has a duty to provide continuity of care when he is traveling or is unable to attend to the patient.

The ‘fiduciary’ nature of the relationship, one that is based on trust, which the patient reposes in his doctor also places an ethical obligation on the doctor to always put the interests of the patient first. Patients rely on doctors for help in their time of need. Regulation 1.2.1 of MCI Code of Ethics requires that “…Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion.”

So, before you undertake a case, if you are planning a visit out of town or a vacation, you still need to take care of your patients.

Communication is the key to developing and nurturing the trust in a doctor-patient relationship. So, if you are going to be away on a vacation or for a conference, etc. also convey the same to your patient. Inform them about the duration of time you would be away and the dates of your departure and return. If you have arranged for another physician to take care of your patients in your absence, then share the names, along with his or her credentials and training, with your patients also. This enables the patient to make an informed decision, whether to continue with you as his doctor. Before doing a surgery, the patient must know that you would not be there for his postop care. Take an informed consent of the patient, otherwise avoid doing the surgery.

A physician is required to be “diligent in caring for the sick” (MCI Regulation 1.1.2). Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family (MCI Regulation 2.4).

Failing to do so might put you at risk for a medical malpractice claim.