Well done to Chai Chung Sien on being a runner-up in the medical student category of our ‘Unofficial Guide to Medicine Essay Competition’ for his essay on “Can you read this? Why do doctors have terrible handwriting? What sort of problems does this cause in the work place? What measures can be put in place to reduce illegibility and error?”
Chai Chung Sien is currently a second year medical student in the University of Dundee. He is at present a student representative for the Dundee University Surgical Society (DUSS). He enjoys participating in activities both inside and outside the medical school and has helped out in a few events organized by the Dundee Malaysian Society (DUMAS). Chung Sien has a special interest in Human Factors and Surgery and is looking forward to do a project integrating the two. Apart from the academics, he especially enjoys listening to the oldies, reading fantasy novels and playing sports.
Can you read this? Why do doctors have terrible handwriting? What sort of problems does this cause in the work place? What measures can be put in place to reduce illegibility and error?
“You may not be able to read a doctor’s handwriting and prescription, but you’ll notice his bills are neatly typewritten.” – Earl Wilson. Doctors’ handwriting has been an ongoing joke for as far back as anyone could remember. They are notoriously known to write with strokes synonymous to chicken-scratches known only to a select few from their line of work. There are, however always two sides to a coin and the age-old question we need to ask is this: do doctors really have terrible handwriting?
A prospective study surprisingly showed that doctors actually do not fare better or worse when compared to non-doctors1 contrary to popular belief. Nonetheless, the study did show that completing a writing task under time pressure led to a lower score in terms of handwriting for both groups involved in the study. In addition to that, another handwriting study showed that although there were statistically significant lower scores by the doctors as compared to nurses, a key thing to note was that a large proportion of the illegible words were in fact contributed by only a handful of doctors in the study2. In light of this evidence, is it possible that this is in fact a living example of a few bad apples spoiling the whole barrel? Could it be that doctors are not actually plagued with bad handwriting but rather, the handwriting of the general population is just plainly bad?
On the other hand, there have been a fair share of studies that have suggested otherwise; that is, doctors do have worse handwriting in comparison to both the medical staff and the non- medical community3-5. Taking into account the substantial workload and the unbelievable amount of paperwork that needs to be done, many have attributed this as the cause for their unique style of writing6. Despite the lack of evidence, it could be argued that their style of writing has been developed further up the line as an adaptive response to all the furious note taking they did while they were still medical students (it certainly feels that way for me).
Having said that, which side of the argument we stand behind does not change the fact that illegible handwriting has been identified as a hazard to the stakeholders involved in healthcare. Illegible handwriting in the medical community carries a much greater risk than that of other professions, in that not much harm would come as a result of not being able to read a business report as opposed to the medical notes of an acute care patient7. This should be taken very seriously as miscommunication within the medical community can very easily snowball into a disaster for the patients. For an instance, a retrospective chart review showed that written notes take 46% and 11% longer respectively to read and to answer questions regarding what was written8. Importantly, these results bring about two implications; firstly, more time is spent on deciphering what was written9 and secondly, information may not be transmitted as effectively and accurately. In other words, this means that more professional time will be wasted and that there is more room for misinterpretation.
Furthermore, misreading the name, dose and frequency of the drug is a very serious problem leading to potentially fatal events. In fact, there have been more than a few cases where death was unfortunately a result following the misinterpretation of the prescription made10,11; one of which occurred due to an anti-anginal drug Isordil being swapped with a calcium channel blocker Plendil10. To illustrate the importance of legibility, a study conducted in a Swiss university hospital showed that 56% of the prescription orders were rated bad or below in terms of readability and that a high incidence of documentation errors found throughout the different stages of the prescribing process were associated with it12.
Ideally, any discrepancies or illegible prescription should be and can be brought to the attention of the prescriber thereby curbing the potential disaster. However, this once again proves the point that the need to do so is simply a waste of professional time. Having said that, all will be good and well if the prescriber’s signature was legible which unfortunately, is not always the case5,7,13. This makes things difficult for the healthcare team as this may lead to inaccurate documentation, potential legal issues and quite frankly frustration as they try to work out the prescriber’s identity. Both the Medical Defence Union and General Medical Council clearly advocates accurate and legible record keeping14,15 . Therefore, it is safe to say that legible medical records have an important role in the medico-legal aspect too.
Illegible handwriting in healthcare is analogous to a time-bomb biding its time. Given the frequency of which drug-related errors occur, it is not an exaggeration but a fact, to say that errors pertaining to drugs represent the most common medical error killing tens of thousands and further harming millions as stated in a report by the US Institute of Medicine16,17. In that very same report, it is stated that an additional 1.9 billion pounds of hospital spending was expended to treat injuries related to drug treatment. While bearing in mind that medication errors could arise from a multitude of system failures ranging from erroneous prescription and calculation to poor medical decision, it cannot be denied that illegible handwriting is one of them12,17,18.
Having concluded that illegible handwriting is a potential risk and hazard, it is now important to consider what can be done about it. Instead of putting the blame on individuals with bad handwriting we should consider why the error occurs in the first place. In order to do so, a holistic systems approach, such as that provided by the SEIPS model19, could be used to identify key elements of the system that could be potentially improved on. At the level of the organization, we could look to education as a possible answer. In response to that, a pilot study was conducted in which handwriting courses were offered to doctors in an effort to improve their handwriting20. Taking into account another study involving education intervention21, both studies showed promising results post-intervention with more legible documentation and signature. With the advent of modern technology, one could also look to employ the use of electronic health systems22. With this, handwriting could be kept to a minimum as records such as prescriptions or instructions are inputted via tablets or computers. In backing this, several studies conducted on computerized physician order entry (CPOE) and closed-loop electronic prescribing showed significant reduction as high as 84% in preventable potential adverse drug events(ADE) and 55% in non-intercepted serious medication errors23-26 proving quite a compelling case as the way forward.
However good that sounds, this does come with its own set of problems such as the cost, problems with adapting to the new system and increased time spent on medication-related task26. In addition to this, voice recognition may one day replace handwriting as the mode of documentation as one study explored the extent of its accuracy and the ethical implications it brings27.With regards to absent or illegible signatures, the use of a name stamp may help improve compliance and adherence to the standard28. Moreover, something simple such as writing or signing in print could help boost legibility21,28. However unlikely, in a stressful environment where the workload is overwhelming , there may be a role for secretaries to play in recording patient notes and prescription as dictated by doctors7 or perhaps verbal orders taken by nurses in acute care scenarios29.
The use of easily misunderstood abbreviations should be discouraged30 given the similarities of the letters (e.g. ON,BD, QID or OD) and the multiple meanings it may possess31.In the same way, units like microgram should not be abbreviated but instead written in full in accordance to the BNF prescribing guidelines32. Every individual doctor has a responsibility in ensuring that the care patients receive are not in any way jeopardized. Having said that, an environment where doctors are able to safely call out on colleagues who are engaged in unsafe practice such as that of their handwriting should be cultivated. Lastly, at the individual level, task reflection and self- assessment is crucial in any stage of training and may help in ensuring that one’s handwriting standard does not fall beyond an unreadable level.
All things considered, handwriting still remains an important aspect of healthcare at least for now. Therefore, it is essential that it is kept to a safe standard where it would not bring about a cascade of errors. Before a joint effort can be instigated, a shift in mentality is first required; there is a need for more awareness and acknowledgement that this is indeed a real problem that shouldn’t just be brushed off and joked about. In conclusion, a collaboration at different levels of the healthcare system is required to tackle this problem and hopefully, one issue at a time, we can begin to mitigate the vast amount of preventable medication errors starting with handwriting. As for myself, I know what I will be practicing tonight.
- Berwick DM, Winickoff DE. The truth about doctors’ handwriting: a prospective study. British Medical Journal. 1996;313(313):1657–8.
- Cheeseman GA, Boon N. Reputation and the legibility of doctors’ handwriting in situ. Scottish Medical Journal. 2001;46(3):79–80.
- Goldsmith H. The facts on the legibility of doctors’ handwriting. Medical Journal of Australia 1976;2:462-463.
- Lyons R, Payne C, McCabe M, Fielder C. Legibility of doctors’ handwriting: quantitative comparative study. British Medical Journal 1998;317:863-64
- Rodríguez-Vera FJ, Marín Y, Sánchez A, Borrachero C, Pujol E. Illegible handwriting in medical records. Journal of the Royal Society of Medicine. 2002;95(11):545–6.
- Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Annals of Internal Medicine. 2016;165(11):753.
- Bruner a, Kasdan ML. Handwriting errors: harmful, wasteful and preventable. Journal of Kentucky Medical Association. 2001;99(5):189–92.
- Kozak E, Dittus R, Smith W, Fitzgerald J, Langfeld C. Deciphering the physician note. Journal of General Internal Medicine. 1994;9(1):52-54.
- Anonymous. A Study of Physicians’ Handwriting as a Time Waster. JAMA: The Journal of the American Medical Association. 1979;242(22):2429.
- Brahams D. Uninsured Pharmacists and Illegible Prescriptions. The Lancet. 1989;333(8636):510.
- Hull L. Doctors’ handwriting so bad it’s putting patients at risk, according to health watchdog who says records are ‘not fit for purpose’ with nurses unable to read them [Internet]. Mail Online. 2017 [cited 22 January 2017]. Available from: http://www.dailymail.co.uk/news/article-2629280/Doctors-handwriting-bad-putting- patients-risk-according-health-watchdog.html
- Hartel M, Staub L, Röder C, Eggli S. High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process. BMC Health Services Research. 2011;11(1).
- Daly P, Moloney F, Doyle M, O’Mahony J. Legibility of Doctor’s Signatures: Novel Approaches to Improving an Age-old problem. Irish Medical Journal. 2006;99(7):214-215.
- Good record keeping – The MDU [Internet]. Themdu.com. [cited 22 January 2017]. Available from: https://www.themdu.com/guidance-and-advice/latest-updates- and-advice/good-record-keeping
- GMC | Keeping records [Internet]. Gmc-uk.org. [cited 22 January 2017]. Available from: http://www.gmc-uk.org/guidance/ethical_guidance/13427.asp
- Roehr B. Institute of Medicine report strives to reduce medication errors. BMJ. 2006;333(7561):220-0.
- Caplan J. Cause of Death: Sloppy Doctors [Internet]. TIME.com. 2007 [cited 22 January 2017]. Available from: http://content.time.com/time/health/article/0,8599,1578074,00.html
- Kohn LT, Corrigan JM, Donaldson MS: To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press; 1999
- Carayon P, Schoofs Hundt A, Karsh B, Gurses A, Alvarado C, Smith M et al. Work system design for patient safety: the SEIPS model. Quality and Safety in Health Care. 2006;15(suppl_1):i50-i58.
- Lazzari C. A corrective approach to doctors’ illegible handwriting: A pilot course in Italy. Medical Teacher. 2012;34(12):1088-1088.
- Glisson J, Morton M, Bond A, Griswold M. Does an Education Intervention Improve Physician Signature Legibility? Pilot Study of a Prospective Chart Review. Perspective in Health Information Management. 2011;8(3):1-11.
- Menachemi NCollum T. Benefits and drawbacks of electronic health record systems. Risk Management and Healthcare Policy. 2011;:47.
- Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review. Journal of American Medical Informatics Association. 2008;15(5):585-600.
- Bates D. Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors. JAMA. 1998;280(15):1311.
- Kaushal R, Shojania K, Bates D. Effects of Computerized Physician Order Entry and Clinical Decision Support Systems on Medication Safety. Archives of Internal Medicine. 2003;163(12):1409.
- Franklin B, O’Grady K, Donyai P, Jacklin A, Barber N. The impact of a closed- loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. Quality and Safety in Health Care. 2007;16(4):279-284.
- Cheshire W. P. Doctors’ handwriting gone digital: An ethical assessment of voice recognition technology in medicine. Ethics and Medicine. 2013;29(2):71–7.
- MacKeith S, Velusamy S, Pajaniappane A, Jervis P. Could Personalised Self-Inking Stamps Improve Identification Standards in Medical Records?. The Bulletin of the Royal College of Surgeons of England. 2012;94(4):128-130.
- West D, Levine S, Magram G, MacCorkle A, Thomas P, Upp K. Pediatric Medication Order Error Rates Related to the Mode of Order Transmission. Archives of Pediatrics & Adolescent Medicine. 1994;148(12):1322.
- Weaver J. It’s Time to Throw Out Old-Fashioned Latin Abbreviations. Anesthesia Progress. 2006;53(1):1-2.
- Medication Safety Tools and Resources [Internet]. Ismp.org. [cited 23 January 2017]. Available from: http://www.ismp.org/tools/abbreviations/
- Joint Formulary Committee. British National Formulary. 70th ed. London: BMJ Group and Pharmaceutical Press; 2015. p. 4-5.
A really excellent essay, written with a lovely writing style that balances a formal scientific tone with light-hearted interjections and humour. This essay is written with a good clear, logical structure to your argument, starting very well by using references and data to look at whether this myth about doctors’ handwriting is supported by any evidence. You clearly have done some detailed research and have a very good understanding of the topic, considering the consequences of bad handwriting on individual patient safety, on healthcare professionals’ workload, and on the NHS as a whole due to the financial implications. Your discussion of possible solutions to this problem are supported very well by references throughout but also show you have put a lot of independent thought into these; Very well done.
Chai took a potentially very mundane topic and wrote an essay that was a delight to read. It was extremely well researched, which was apparent from the depth and breadth of the argument, as well as the extensive references. With regards to style, the essay was very well structured with a humourous touch, making it all the more successful. Well done on a fantastic account of an age-old debate.