Writing an illegible
prescription
A SPECIAL REPORT
The following closed claim studies
are based on actual malpractice
claims from Texas
Medical Liability Trust. These cases
illustrate how action or inaction on
the part of physicians led to allegations
of professional liability, and
how risk management techniques may
have either prevented the outcome or
increased the physicians’ defensibility.
The ultimate goal in presenting
these cases is to help physicians practice
safe medicine. An attempt has
been made to make the material more
difficult to identify. If you recognize
your own claim, please be assured it is
presented solely to emphasize the
issues of the case.
Presentation
A 43-year-old obese man came to
the emergency department (ED) with
complaints of shortness of breath and
ankle edema. His cardiologist was contacted
and the patient was admitted to
the hospital. The patient had a complex
medical history including congestive
heart failure, coronary artery disease,
insulin-dependent diabetes and
had suffered two cerebral vascular accidents.
Previous surgeries included two
aortic valve replacements and pacemaker
implantation. In spite of the
aortic valve replacements he continued
to have 4+ aortic regurgitation.
Physician action
During his hospitalization the
patient was treated with Lanoxin, intravenous
Lasix and Isordil. His symptoms
improved and approximately one
week later he was discharged in stable
condition. At the time of discharge he
was given prescriptions for Lasix,
Isordil, Coumadin, Humulin insulin,
Digoxin, Captopril, K-Dur and iron.
The patient’s wife had the prescriptions
filled at a local pharmacy. The pharmacist
misread the prescription for Isordil
and dispensed Plendil, an antihypertensive.
This was done even though the
prescribed dosage intended for Isordil
was eight times the normal dosage for
Plendil. At no time did the pharmacist
contact the cardiologist to clarify the
prescription.
Two weeks following his discharge,
the patient returned to the ED complaining
of intermittent chest pain. The
pain was unresolved with nitroglycerin.
The ED physician reviewed the
patient’s medications and noted that
he was taking Plendil. The patient was
again admitted to the hospital by the
cardiologist with a diagnosis of chest
pain. The admission note in the chart
stated, “…etiology probable unstable
angina precipitated by excessive doses
of medication (Plendil)…”
The patient was transferred to a
major medical center for cardiac transplantation
evaluation. Based on the
patient’s multiple, complex medical
problems it was determined he was
not a candidate for heart transplant.
He died two weeks later.
Allegations
The patient’s family filed a lawsuit
against the cardiologist alleging he
wrote an illegible prescription and was
negligent in the care of the patient.
Subsequently, the pharmacist dispensed
the wrong medication, resulting
in the death of the patient.
Legal implications
The cardiology expert witness for
the plaintiffs stated that he felt “strongly”
that the excessive dosage of Plendil
caused further degeneration of the
patient’s condition. Expert testimony
by defendant expert witnesses, including
both prior and subsequent treating
physicians, stated emphatically that
there was no injury to the patient as a
result of the Plendil. The court also
noted that regulations require a pharmacist
to confer with the physician
if there is any question regarding a
prescription.
Disposition
This case was tried to a jury verdict.
The jury believed the incorrect dose of
Plendil resulted in the death of the
patient. They ruled that the pharmacist
was at fault for misreading the prescription,
and that the pharmacist had a
responsibility to notify the physician if
he could not read the handwriting.
Additionally, the jury wanted to “send a
message” to the cardiologist regarding
his handwriting and ultimately decided
that both the cardiologist and the pharmacist
were negligent. The plaintiffs’
award was split evenly between the
pharmacist and the cardiologist.
Risk management considerations
The Texas Medical Board rules pertaining
to medical records states, “Each
licensed physician of the board shall
maintain an adequate medical record
for each patient that is complete, contemporaneous
and legible.” (1) Therefore
the physician is required to write
legibly so that both the physician and
any subsequent treaters are able to read
the contents and act accordingly. Illegible
handwriting, either in the medical
record or on a prescription, creates the
potential for misinterpretation leaving
the patient vulnerable to a medical
error, possibly resulting in an injury.
Legible handwriting has long been a
challenge for physicians and others
reading the records who rely on the
information to provide further care to
the patient. As demonstrated in this
case, the physician’s illegible handwriting
resulted in the pharmacist prescribing
the wrong medication and the
wrong dosage. Although it may be
more time-consuming, physicians with
poor handwriting may want to consider
printing the names of medications
on a prescription. Electronic medical
records or computer-generated prescriptions
may be a solution for some.
While they are not a panacea, they
generally eliminate the difficulties presented
by illegible handwriting.
The information and opinions in this
article should not be used or referred to
as primary legal sources nor construed as
establishing medical standards of care for
the purposes of litigation, including
expert testimony. The standard of care is
dependent upon the particular facts and
circumstances of each individual case
and no generalization can be made that
would apply to all cases. The information
presented should be used as a resource,
selected and adapted with the advice of
your attorney. It is distributed with the
understanding that neither Texas Medical
Liability Trust nor Texas Medical
Insurance Company is engaged in rendering
legal services.
