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  • Louvenia Ringuette, RN BSN

Penmanship - A Cause of Medical Errors

I began this blog in my head after going through piles of much needed weeding of old paperwork. Living in the same house for over 20 years lead to an accumulation of “treasures”. My heart breaks and sings with joy as I discover an old signed check I had written my mom over 35 years ago. It breaks my heart because my mom is no longer with us. Oh how I miss her. My heart sings with joy because of the memories I have of her and of our time together. But what still grabs me was her precious beautiful handwriting. She did not add a whip to her letters, or do anything fancy, she just signed her name with perfect cursive style. All letters the same size, except capitals of course, and every single cursive letter perfectly formed and readable. Mom always contributed her excellent cursive writing skills to the hours her school and parents made her practice. Why are schools doing away with cursive writing?

Just this past weekend I gave my grandson a birthday card, signed proudly by his grandma. He reads the card and gets to my signature and the words I wrote, and he stated, “You know I can’t read cursive” In years to come when he picks up this card and looks at it, will it give him that same heart sing I felt looking back and reading my mom’s handwriting? A type writer, or computer written card or letter just doesn’t have the same effect, despite the fact the letters are the same size, and in a straight line, and the person writing it puts meaning to the words but still it is just a “font”. Sorry for the digressing onward with my blog post which shows the other side of penmanship.

Handwriting in the medical field

It is imperative that a nurse or other health care provider is able to read what a prescriber wrote. Legible handwriting can be the difference between life and death in the medical field. As a nurse I have seen a lot of handwriting, and often could not read half of what I have seen. In a 2016 article written by Alan Sacken, Attorney, he wrote that many people are unaware of how serious a prescriber’s poor penmanship can be. He cites a study that found a shocking 37 errors/100 handwritten prescriptions (37%)due to poor penmanship. The study noted that the nurse or other healthcare providers inability to read what had been written directly contributed to the medication error. Other articles read cite the error rate as possibly higher due to under reporting of medication errors. As a bedside nurse I saw many examples of poor penmanship and medication errors or near miss medication errors. In nursing school, I was taught if you cannot read what the prescriber wrote you have the responsibility to contact that prescriber to have them read what they wrote. However, in reality, some prescribers exhibit intimidating behaviors, staff time restraints due to heavy patient loads, and understaffing are just a few reasons why some nurses prefer to go to another nurse, or staff to ask what they think the provider wrote. It is scary when three nurses are looking at the same piece of paper and all three see something different. Just one letter or a decimal off, can cause patients ill effects or even death. Many facilities have implemented policy and procedures to help reduce the possibility of medication errors that occur because of poor handwriting. I worked for employers that required the prescriber to read you what they wrote and ask if you had questions prior to them leaving the floor. This practice was not well enforced as nurses and prescribers where often not available at the same time.

Besides the prescriber’s poor penmanship, other staff members are often responsible for medication errors as well. While working in a Skilled Nursing Facility I saw healthcare providers write many orders for new medications, or for medication dosage changes. These orders usually needed to be implemented that day meaning someone from the nursing team, or unit had to read the new order and write the order on the medication administration record (MAR) so the medication nurse could provide the needed medication. The medication nurse than had to trust that the person writing the order on the medication sheet had read the order and transcribed it correctly. The nurse or person transcribing the medication was often in a hurry and would quickly scribble the order on the medication sheet making it difficult for the medication nurse to read and administer the correct medication, in the correct dosage, to the correct patient. More than once have I seen a new order written on another patient’s medication sheet because that person’s medication sheet had been filed under the wrong patients’ tab in the medication book.

In many states the State Department of Health Agencies have taken some extra ordinary steps to help reduce medication errors and protect the public. In fact, as noted in an article in the New York Times, New York took these issues seriously and in 2016 they mandated all prescriptions had to be electronically submitted directly to the pharmacy, and was the first state to mandate it with penalties, such as fines to imprisonment for those that did not comply. Handwritten prescriptions were only allowed to be written under certain limited circumstances. Minnesota was the first state to implement electronically submitted prescriptionsin 2008 but did not put measures in place to enforce it as New York has done. In a Surescripts report, the company that handles the software for the electronic transmission states that studies show that the implementation of electronic prescribing have shown positive results in reducing medication errors, and in opioid fraud.

Many other measures are in place to help reduce medication errors. While attending nursing school to become a License Practical nurse, I was taught many abbreviations used in writing medication orders so I could follow the prescribers order, however, when I went back to school several years later for my Registered Nursing degree many of the abbreviations had been removed from the curriculum and hospitals had a “DO NOT USE ABBREVATION” list in the front of each chart. This move from some of the abbreviations did not surprise me. Where is the logic that you’d write OS for the left eye, OD for the right eye and OU for both eyes? Federal and State agencies have joined in the fight to move health care industry into the digital age, in hopes to provide customers a holistic, safer health care delivery by implementing a law that requires all healthcare facilities to have an electronic health care record by 2015. Those out of compliance will be facing penalties.

There are many factors that contribute to medication and other medical errors. Each week this month I will provide more information regarding medication errors.

Healthcare workers have taken an oath to do no harm. When in doubt staff must go to the source for the truth. This will not only protect a professional license you worked so hard to get, but, it potentially could save a patient’s life. As a Certified Legal Nurse I can help you identify medication errors and causes.

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