Report: Electronic Prescriptions Needed to Reduce Medical Errors

Published October 1, 2006

Doctors’ indecipherable handwriting, often the punch line of jokes, has been thrust into the national spotlight by a recent study calling for sweeping legislation to curb the dangers of medical illegibility.

Several states have passed laws regarding the matter, and calls for federal standardization are beginning to surface. But at least one study has shown electronic prescriptions cause even more medical errors, and privacy concerns surround the issue as well.

According to “Preventing Medication Errors,” released in July by the Institute of Medicine (IOM), a national nonprofit group that is part of the National Academies of Science, medication errors injure 1.5 million patients annually and cost $3.5 billion each year. Among the chief culprits is what has been called “death by handwriting”–harmful drug interactions stemming from an inability to decode doctors’ illegibly scrawled prescription orders.

That, combined with nurses confusing drugs between patients and pharmacists dispensing incorrect dosages, the study said, have created a situation in which a patient experiences an average of one medication error each day he or she spends in a hospital.

Need to Intervene

Health care workers’ reception to the report, which calls for a ubiquitous program for issuing electronic prescriptions by 2010, were mixed.

“Some have been skeptical, suggesting that our time might be better spent lobbying payers for better reimbursement to help improve the quality of the work force and other worthwhile goals,” said Dr. Albert Wu, a professor of medicine at Johns Hopkins University and coauthor of the IOM report. “Others have congratulated the committee on formulating a detailed set of recommendations for all stakeholders.”

But according to a study published in the March 9, 2005 issue of the Journal of the American Medical Association, computerized physician order entry systems “facilitated 22 types of medication error risks including double dosing and incompatible orders, and inflexible ordering formats generating wrong orders,” wrote lead author Ross Koppel, Ph.D. of the University of Pennsylvania’s Center for Clinical Epidemiology and Biostatistics. “Three-quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often.”

Twila Brase, president of the Minnesota-based Citizens’ Council on Health Care, called the IOM proposal a “seriously bad idea” that essentially creates a nationalized health care system suffocating the free exchange of information on medications, and adding layers of bureaucracy to an already-burdened system.

“Every doctor’s order and every patients’ medication would be monitored,” Brase explained. “No more going to the pharmacy without your doctor knowing which one you went to. No more choosing not to follow doctors’ orders because you really didn’t want that drug without your doctor, your health plan, and eventually the government knowing.

“The IOM wants every prescription to be ‘subject to evidence-based, current clinical decision support,'” noted Brase. “In other words, the IOM wants every prescription decision to be subject to outside control. If the IOM has its way, doctors will be required to subject their every medication decision to the political agendas of people outside the exam room.”

State Control

More than four billion prescriptions are issued in the United States each year. As prescription drug usage increases, so does the threat posed by illegible writing and, some say, the need for federal intervention.

With no political move underway for national legibility standards, states have increasingly sought to control doctors’ handwriting, with mixed results.

In June, the state of Washington enacted a law forbidding health care providers from writing prescriptions in cursive script. The measure requires that all prescriptions either be electronically generated, typewritten, or hand printed, to ensure pharmacists and other practitioners can easily decipher complex drug names. Lisa Salmi, acting executive director of the Washington Board of Health, said most doctors “are now aware of the new law and are printing prescriptions.”

“The new law has increased the pharmacists’ and prescribers’ awareness of medication error prevention,” Salmi said, adding that most are now being hand printed, though a few pharmacists report still receiving cursive prescriptions.

Similar “safe script” laws have passed in Florida, Idaho, Maryland, Montana, and Tennessee. Doctors in Montana face fines of up to $500 for handwriting pharmacists say is illegible.

“It’s going to be federal or state” law eventually, said Michael Fumento, a senior fellow at the Hudson Institute in Washington, DC. Fumento said in this instance a federal law is a good idea because people nationwide are equally affected by prescription drug errors. “I’d rather see [states] follow Washington’s lead. But that will take a long time.”

Common Call

A landmark 1999 lawsuit underscored for many Americans the dangers of sloppy prescription writing. In Teresa Vasquez et al. v. Ramachandra Kolluru, a jury fined a Texas cardiologist $225,000 for scrawling a prescription for Isordil, a drug that combats heart pain, which a pharmacist misread as Plendil, which controls high blood pressure. The mistake killed Ramon Vasquez, who died of an overdose-induced heart attack.

Efforts toward national electronically written prescribing standards, like those in the IOM report, have stalled. In 2000, the Institute for Safe Medication Practices, the nation’s only nonprofit organization devoted entirely to medication error prevention and safe medication use, unveiled calculations claiming medication errors cause more deaths in the United States per year than workplace injuries.

The group called for an end to all handwritten prescriptions “within the next three years.” In 2000, the IOM reported medication errors caused 7,000 deaths a year.

Difficult Proposition

Though federal agencies seem receptive to the idea, Wu said implementing electronic prescriptions nationwide by 2010, as the IOM recommends, may prove difficult.

“Electronic prescribing will take careful planning and real investment,” Wu said. “Hospitals, practices, and other organizations will need to budget for and install systems. Pharmacies will need to obtain systems to receive these transmissions. Physicians will need to embrace the new technology, begin using it, and help determine how it can be improved.”

Gregory Brown ([email protected]) is a freelance writer in New Rochelle, New York.

For more information …

“Preventing Medication Errors: Quality Chasm Series,” Institute of Medicine, July 20, 2006,

“Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors,” by Ross Koppel, Ph.D. et. al, Journal of the American Medical Association, March 9, 2005, Vol. 293, No. 10, 1197-1203,