Intended for healthcare professionals


Family compensated for death after illegible prescription

BMJ 1999; 319 doi: (Published 04 December 1999) Cite this as: BMJ 1999;319:1456
  1. Fred Charatan
  1. Florida

    A Texas jury has attributed the death of a 42 year old patient to an illegible prescription and has ordered the doctor who wrote it to pay $225000 (£140625) compensation to the patient's family. The total judgment of $450000 included an equal award against the dispensing pharmacist.

    The doctor, cardiologist Dr Ramachandra Kolluru, wrote a prescription for 20 mg Isordil (isosorbide dinitrate) for angina, every six hours. But, because of the illegibility of the prescription, argued Kent Buckingham, lawyer for the family of the patient, Ramon Vasquez, the pharmacist dispensed the same dosage of Plendil (felodipine), a calcium channel blocker used in the treatment of hypertension, for which the maximum daily dose is only 10 mg. A day after taking what equalled a 16% overdose of felodipine, Mr Vasquez had a heart attack and died several days later. The overall quality of care given by Dr Kolluru was not at issue, the trial heard; his illegible prescription was the sole reason for the judgment.

    The case again raises the issue of the legibility of doctors' handwriting. Mr Buckingham pointed out: “Many doctors are having to stop and think, ‘By golly, that prescription I wrote illegibly this morning may result in an adverse verdict.’”

    Three policies issued over the past seven years by the American Medical Association have urged doctors to “improve the legibility of handwritten orders for medications” and to review all orders for accuracy and legibility. Doctors with poor handwriting are advised to use direct, computerised order entry systems or at least to print or type medication orders.

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    Poor handwriting of a prescription led to patient's death

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