A handwritten doctors’ note is the frequent butt of jokes, but a new medical case study is showing how this old cliché could potentially spell real danger for patients.
A woman in Scotland was accidentally given erectile dysfunction cream instead of eye ointment for dry eyes because the chemist misread the doctor’s shoddy handwriting, as detailed in BMJ Case Reports last month.
It's fairly easy to see how the blunder came about. The erectile dysfunction cream is called “Vitaros” and the ocular lubricant is called “VitA-POS." The error was not spotted by the GP, pharmacist or the patient, so she ended up applying the cream to her eyes.
The active ingredient in the erectile dysfunction cream is alprostadil, a naturally occurring chemical that dilates blood vessels. When applied to the skin (or, you know, the penis) it will increase blood flow to the area. However, as you can imagine, it can acutely irritate the eye.
Fortunately, she made a full recovery with some simple treatment of topical antibiotics, steroids, and lubricants, but the mild chemical injury still caused her to suffer from eye pain, blurred vision, redness, and swollen eyes.
"We would like to raise awareness that medications with similar spellings exist," Dr Magdalena Edington of the Tennent Institute of Ophthalmology in Glasgow wrote in the case study. "We encourage prescribers to ensure that handwritten prescriptions are printed in block capital letters to avoid similar scenarios in the future."
Don't worry, she did also point out the obvious, which you are all no doubt thinking: "It is unusual in this case that no individual (including the patient, general practitioner or dispensing pharmacist) questioned erectile dysfunction cream being prescribed to a female patient, with ocular application instructions.”
The study authors say they thought this was an important issue to raise in a case study, to promote awareness and safe prescribing skills. These kinds of errors happen a surprising amount, occasionally with deadly results. Last year, a report found that health care professionals in England make around 237 million prescription screw ups each year, such as providing patients with the wrong medication or prescribing the wrong dose. It even suggests that these errors are responsible for 700 deaths each year, and could play a significant factor in the deaths up to 22,300 others.