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Handwritten prescriptions have traditionally been a staple of medical practice, but when legibility is poor, they can create misunderstandings, and sometimes, grave danger. “There have been real cases in which a patient took the wrong medication or wrong dose simply because the script was illegible,” said Dr Amit Saraf, director, internal medicine, Jupiter Hospital, Thane.
One such case involved a 34-year-old man with a throat infection. His doctor prescribed an antibiotic, but the pharmacist misread the note and dispensed a strong steroid instead. “Within two days, the infection worsened, and he developed severe stomach pain and weakness. Another doctor later admitted he too struggled to read the original prescription. The patient had to be hospitalised for IV antibiotics before recovering,” recalled Dr Manjusha Agarwal, senior consultant, internal medicine, Gleneagles Hospital Parel, Mumbai.
In another instance, a neurosurgeon prescribed azidothymidine (AZT) for HIV prophylaxis after a needle-stick injury. The illegible script led the pharmacist to supply azathioprine, a powerful immunosuppressant. “For a month, the neurosurgeon unknowingly took the wrong drug, developed high-grade fever, and was found to have pancytopenia, a toxic effect of azathioprine. A life-saving prescription became life-threatening,” said Dr Kumar.
Even small errors can prove dangerous. A patient admitted for peripheral neuropathy was prescribed 0.5 mg alprazolam at night. The doctor wrote “.5 mg” instead of “0.5 mg”. The decimal point was missed, and the patient was given 5 mg instead. “She was later found in a semi-comatose state from excessive sedation, all due to a missing zero,” Dr Kumar pointed out.
These are not isolated incidents. They reflect a systemic issue: unclear handwriting can lead to fatal drug errors. “Prescriptions are meant to heal, but when written carelessly, they can sometimes harm. Illegible handwriting in medical practice is not a trivial matter; it can lead to dangerous errors with devastating consequences for patients,” described Dr Kumar in an interaction with indianexpress.com.
Even medical professionals sometimes misinterpret scripts, delaying treatment or, in rare cases, injuring patients. “A simple mix-up of letters or dosage instructions can alter the entire course of treatment,” noted another physician who did not wish to be named.
The judiciary has also intervened. The Punjab and Haryana High Court recently held that a legible prescription is a “fundamental right” since it can be the difference between life and death. Dr Dilip Bhanushali, president of the Indian Medical Association (IMA), told BBC that while poor handwriting is widespread, especially in overcrowded government hospitals, the association has advised members to follow guidelines and write in block letters. “A doctor who sees seven patients a day can do it, but if you see 70 a day, you can’t,” he admitted.
Shifting to electronic prescriptions
To counter the risks, many hospitals are moving towards electronic prescribing. “Doctors now enter prescriptions into a computer or tablet, which generates a typed version. This is common in urban centres and slowly spreading to smaller clinics as well,” explained Dr Saraf.
The IMA has repeatedly emphasised that prescriptions should be typed or written in block letters. “Typing prescriptions is simple patient-safety hygiene,” said Dr Karuna Malhotra, aesthetic physician and cosmetologist, Cosmetic Skin and Homeo Clinic, New Delhi.
Why typing matters
Typed prescriptions eliminate ambiguity. They make drug names, dosages, and frequencies clear for both pharmacists and patients. “This reduces the risk of errors, saves time, builds trust, and creates a trackable digital record for future reference,” Dr Saraf noted.
“In medicine, clarity is not optional; it is a matter of life and death,” Dr Kumar reiterated.
How do pharmacists cope with messy handwriting?
Pharmacists often rely on experience and context to decipher illegible prescriptions, using the patient’s diagnosis and standard drug choices for the condition to make educated guesses. When in doubt, they place clarification calls to the prescriber — a process that is frequent and time-consuming — or check the patient’s prior medication history to match the likely drug. To reduce risks, pharmacies also use tall-man lettering and special labelling for look-alike or sound-alike drugs, along with barcode scanning, cross-checks, and patient counselling before handover. Despite these safeguards, pharmacists caution that errors are only a misread away, making it essential to go only to a licensed pharmacy, preferably one recommended by the attending doctor, as Dr Karuna Malhotra advised.
What can patients do?
Patients, too, play a role in staying safe:
– Double-check prescriptions with the pharmacist.
– Ask questions if handwriting is unclear.
– Request a typed or digital copy whenever possible.
“Using typed prescriptions is an easy and efficient way to ensure safety, ease of access, and reliability in treatment,” said Dr Saraf.
DISCLAIMER: This article is based on information from the public domain and/or the experts we spoke to. Always consult your health practitioner before starting any routine.
