PLEASE CAPS LOCK YOUR PRESCRIPTIONS & SAFE LOCK MANY LIVES’- SAYS MEDICAL COUNCIL OF INDIA

PLEASE CAPS LOCK YOUR PRESCRIPTIONS & SAFE LOCK MANY LIVES’- SAYS MEDICAL COUNCIL OF INDIA

Chinnu P.B and Mary Raju Mathew

Pharm. D 5th Year,Dept of Pharmacy Practice, Alshifa college of Pharmacy

In 2011, a 52-year old man was prescribed Lansoprazol (APRAZOL^® tablet) for his duodenal ulcer, but the pharmacist misinterpreted the writing in the prescription as Naproxen Sodium (APRANAX^® tablet), and dispensed it instead of Lansoprazol. Shortly after starting the medication, he was hospitalised with upper gastrointestinal bleeding. After his recovery, the patient filed a lawsuit against the pharmacy in the criminal court at first instance. At the end of trial, the court’s decision was both the pharmacist and his assistant were mainly responsible for jeopardising the patient’s health. They should have contacted with the prescribing doctor if any doubt existed about the name of the drug that was being prescribed. According to the decision, the doctor’s responsibility was negligible than the others. On February 22, 2012, a Hyderabad-based pregnant woman was advised MICROGEST^® 200 mg which is used for foetus growth. So illegible was the writing in the prescription that the pharmacist mistook MICROGEST^® for MISOPROSTOL — which is used for abortion.
The woman lost her baby.

The harm done due to illegible prescriptions and the inability to read them has cost many lives over the years in India. Unless physicians bid adieu to illegible handwriting, the hazard of misinterpretation will linger along.  A 47-year-old pharmacist Chilkuri Paramathma from Telegana has a similar view, like many of the pharmacists and medical doctors in India. He has gone from door to door, has used the Right to Information Act, filed Public Interest Litigation and wrote innumerable letters to the Union health ministry, the Medical Council of India, the Drugs Controller-General of India (DCGI) and the Director-General of Health Services (DGHS) to make sure a change is brought in and the prescriptions written by practising doctors are more legible, hence saving the confusion to pharmacists and the risk it poses to patients otherwise. The US Food and Drug Administration recognises that bad handwriting leads to medication errors and demands that drug names are tested by simulating the process of dispensing drugs using handwritten prescriptions. Six American states have passed legislation making doctors’ illegible handwriting a fineable offence.

In India the Union Health Ministry has lately sprung up into action- thanks to the tireless travail by Paramathma. The Health Ministry is bringing in a gazette notification, very soon, wherein doctors will be demanded to write names of medicines, their dosage, strength, duration and total quantity in capital letters and to put down the generic names of the drugs prescribed as well, and Medical Council of India (MCI) is circulating a prescription format for the doctors to all state medical councils across the country.

Doctors across the country have welcomed this move saying that it’s worth the effort if it helps patients and at same time they express concern that this system may take a little time to get used to. Even then, if it’s mandated in the country to write prescriptions in capital letters, it would undoubtedly be the best move to ensure safe prescriptions.

Collective efforts and awareness can help ending the growing problem of illegible handwriting among medical professionals. Wider adoption of e-prescribing could lead to further efficiency in reducing errors, even then writing a medicine’s name in capital letters still remains a safe yet cheaper way to reduce prescription and dispensing related errors.

CAPITILAZED PRESCRIPTIONS CAN LOCK IN PATIENT SAFETY!