The Pharmaceutical Journal
Vol 270 No 7235 p178
8 February 2003

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Chief Medical Officer update (more)

Warning: poor handwriting can kill

The chief medical officer, Sir Liam Donaldson, has written to doctors warning them of the potential for medication errors arising from illegible handwriting.

He says that the root causes of medication errors are diverse but that a cause that continues to occur regularly arises from misunderstanding or misinterpreting hand-written prescriptions or instructions for the administration of medicines. In his letter, Sir Liam describes the case of a man who died as a result of a warfarin overdose after the word "Same" was misinterpreted as 5mg. This led to the man's usual dose of warfarin being doubled.

"We ask all doctors to be aware of the potential harm that can result from illegible handwriting or the use of abbreviations. Diligence will save lives," he says.

The National Patient Safety Agency intends to review incidents of medication errors with anticoagulants and will be seeking to identify best practice to improve their safe use later this year.