Recently, a cardiologist and a pharmacist were held liable for a fatal medication error caused by poor handwriting. The physician had prescribed the vasodilator Isordil (isosorbide dinitrate), 20 mg P.O. every 6 hours, and hadn't included the drug's purpose. The pharmacist, who misread the drug name as Plendil (felodipine), didn't question the high dose (the maximum recommended dose for felodipine is 10 mg daily). After taking felodipine (a calcium channel blocker) for a day, the patient suffered a myocardial infarction and died.
If you can't read handwriting, never guess or ask another person what it says, which wastes your time and can endanger your patient. Call the practitioner who ordered the medication to clarify the order and to include the purpose.
Copyright Springhouse Corporation Feb 2000
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