Although electronic prescribing has reduced the problem, illegible handwritten prescriptions can still pose a patient safety risk by increasing the potential for medication errors.

“Handwritten prescriptions, even my own, are almost illegible. And the problem gets worse when we write compounded prescriptions, in which mg, ingredients, excipients, and instructions for use take on added importance.”

Speaking with El Médico Interactivo on Univadis, part of the Medscape Professional Network, Aurora Guerra-Tapia, MD, PhD, medical director of Dermatólogas Guerra, full professor of dermatology at the Complutense University of Madrid, Spain, and former head of the Dermatology Department at University Hospital 12 de Octubre in Madrid Sergio Vañó Galván, MD, dermatologist, trichologist and hair surgeon, professor and director of the Trichology Unit of the Ramón y Cajal University Hospital and the Pedro Jaén Group, Madrid, and Carme Rigall, pharmacist and president of the Federation of Pharmacy Associations of Catalonia (FEFAC) reflected on the longstanding reputation of physicians’ handwriting.

“My mother used to say about my handwriting, ‘I’ll write it, and the devil can read it,” Guerra-Tapia recalled. She attributed her handwriting to years of taking notes at breakneck speed during medical school and writing quickly while seeing a large number of patients. Although electronic prescribing has alleviated much of the problem, she doubts that physicians’ handwriting would have improved if paper prescriptions were still the norm. “Bad handwriting’ is part of a doctor’s idiosyncrasy,” Guerra-Tapia said.

Perhaps because of what Guerra-Tapia described, the idea of “doctor's handwriting” has become firmly rooted in the public imagination. In Spanish, this type of illegible handwriting even has its own term, garambaina, defined by the Royal Spanish Academy as “ill formed letters or strokes that cannot be read.”

Vañó Galván, humorously admitted that his own handwriting would fit perfectly with the Royal Spanish Academy’s definition of “garambaina,” or illegible scribbles. “I’ve long realized that my handwriting isn’t exactly great, it’s ‘doctor’s handwriting.’ I try to improve it, but it is a difficult task. However, we must be aware of the importance of this for our patients.”

“I’ve realized for some time that my handwriting isn’t particularly good — it’s ‘doctor’s handwriting,” he said. “I’ve tried to improve it, but it’s difficult. At the same time, we need to recognize how important legible handwriting is for our patients.”

Compounded Prescriptions Increase the Risk

Vañó recalled that when oral minoxidil was initially prescribed as a compounded medication, handwritten prescriptions occasionally resulted in serious dosing errors because pharmacists misread the prescribed strength.

“The doses range from 0.5 mg-5 mg/capsule,” he said. “I remember several cases in which patients experienced significant adverse effects because the pharmacist could not correctly interpret the physician’s handwriting. In one particularly serious case, 1 g/capsule was prepared instead of 1 mg. That illustrates how important clear handwriting can be.”

When Pharmacists Cannot Read a Prescription

Interpreting handwritten prescriptions remains a familiar challenge for pharmacists.

Handwritten prescriptions from physicians can be a real challenge for pharmacists to decipher, and many share photos of especially difficult examples on social media with captions such as “Rubio’s Advanced-Level Exam” or “This doctor must have missed a couple of workbooks as a kid.” The references are to the famous Rubio workbooks, first published in Spain in the late 1950s, to help children develop clear handwriting skills and master basic arithmetic.

When pharmacists cannot decipher a prescription, they may first rely on their clinical judgment to search for clues that might help identify the intended medication. If this does not work, they may consult colleagues at the pharmacy, which is why it is not uncommon for two or three pharmacists to review the same prescription. If they still cannot determine what was prescribed, they may contact the prescribing physician — the safest way to avoid medication errors caused by confusion between similarly named or similarly spelled medications.

“Never blindly,” said Rigall.

Poor handwriting can seriously jeopardize patient safety. Illegible handwriting can lead to fatal medication errors in extreme cases.

One widely cited case from 2000 involved a $450,000 settlement awarded to the family of a patient after a physician prescribed 20 mg of isordil, a medication used to treat heart failure, which a pharmacist misread as plendil, an antihypertensive whose maximum recommended dose is 10 mg/d. The patient died after taking an overdose of plendil for 6 days, and both the physician and the pharmacist were required to pay half of the settlement.

Doctors’ Handwriting, According to Studies

Classic studies, such as that by Goldsmith published in 1976, suggested that physicians’ handwriting is less legible than that of other professionals. This study examined the handwriting skills of physicians and other professionals. Each participant’s handwriting was evaluated, and four different statistical tests were performed. In every analysis, physicians’ handwriting received lower legibility scores.

Studies conducted in Spain have reported similar findings. One study published in 2002 examined handwritten medical reports from general medicine, cardiology, gastroenterology, respiratory medicine, neurology, oncology, and several surgical specialties at a national hospital and found that 15% were partially or completely illegible. Although this percentage may not seem particularly high, the investigators concluded that these cases were preventable and could be addressed by switching to a prescription system that did not require handwritten notes. The surgeons had the lowest legibility scores.

A review published in 2014 in the Journal of Osteoporosis and Mineral Metabolism also summarized studies and experiments conducted since the 1960s that examined the longstanding perception that physicians’ handwriting is difficult to read.

Other studies have challenged this view. A well-known study suggested that poor handwriting by physicians may be a statistical myth. After evaluating hundreds of professionals from different occupations, the researchers found that physicians wrote no better or worse than anyone else.

In another study, researchers selected 20 participants from seven professions: Lawyers, construction workers, scientists, physicians, mechanics, and engineers — and asked them to write the same sentence in 17 seconds. Physicians’ handwriting was neither better nor worse than that of the other groups. However, the study included only 20 participants, and because they knew that they were taking part in the experiment, they might have made a greater effort to write clearly.

As Guerra-Tapia noted earlier, technological advances have reduced the need for handwritten notes in medical schools. Modern computers can even record lectures, helping to alleviate the problem. Paradoxically, a free computer font inspired by physicians’ handwriting mimics its irregular form for use on computers. It is an ironic nod to a reality that seems to persist, as though medicine, even in its most technologically advanced form, is reluctant to abandon its own quirks.

This article was translated from El Médico Interactivo on Univadis.