Prescription Errors You Won’t Believe Actually Happened

"Bad Handwriting, Worse Outcomes: When Your Scribble Becomes Someone’s Suffering"

Let’s talk about a classic inside joke in medicine: “Doctors’ handwriting is a cryptic language that only pharmacists and ancient codebreakers can decipher.” While that might get a chuckle in a hospital hallway or a meme on social media, it’s not that funny anymore. In fact, it’s dangerous.

In the age of AI, robotic surgeries, and smart stethoscopes, it’s hard to believe that in many parts of the world, doctors still write prescriptions by hand. And not just hand-written – illegibly hand-written. As if we’re deliberately challenging the poor pharmacist’s eyesight.

But let’s be clear: this isn’t just about messy penmanship. It’s about preventable harm.

Real Case #1: The “Diflucan Disaster”

Let’s start with a personal anecdote – a patient once told me that her daughter was prescribed Diflucan 150 mg – two capsules monthly. It was meant to be taken once every two weeks. But the way it was written, she read it as two capsules per month, and just gave them both together at the start of the month. The handwriting? A spaghetti mess of “2 cap. q month.”

The mother, not being medically trained, couldn’t decode this medical cipher. Result? Misuse of antifungal therapy for recurrent vaginal candidiasis. Treatment failure. Ongoing symptoms. Frustrated mother. Embarrassed doctor.

Now multiply this story across rural clinics, overcrowded hospitals, and thousands of prescriptions – and you start to see the bigger picture.

Real Case #2: “Insulin or Isordil?”

A nurse in an overworked ward in South Asia once reported giving Isordil (isosorbide dinitrate) instead of Insulin. Why? The doctor wrote a sliding scale for insulin in handwriting that could’ve easily been the ancient Sumerian alphabet.

Thankfully, the patient only had a mild hypotensive episode and recovered. But the incident went unreported, brushed off as a simple error. But there’s nothing simple about a mix-up that could’ve caused a diabetic coma.

Real Case #3: “MSO4 vs MgSO4”

This one is infamous. MSO4 stands for morphine sulfate, while MgSO4 is magnesium sulfate. The Joint Commission in the U.S. literally banned this abbreviation due to the frequency of errors.

In one case, a patient in a maternity ward received morphine instead of magnesium for preeclampsia due to misreading an order. That mix-up almost caused respiratory arrest. Thank goodness the nurse double-checked. But would every nurse have caught that?

Real Case #4: “Eye or Ear Drops?”

A pharmacist once dispensed chloramphenicol eye drops instead of ear drops. Why? Because the scrawled script didn’t clearly distinguish “aur” (aural) from “ophth” (ophthalmic). The patient had an ear infection, but ended up using eye drops in the ear – not harmful, but completely ineffective. The infection worsened, and the patient had to visit A&E for complications.

Real Case #5: “Daily or QID?”

A hypertensive patient ended up taking Amlodipine four times a day instead of once. Because the prescription scribbled “qd” (once daily) – but looked like “qid” (four times daily). The patient developed significant hypotension, dizziness, and had to be hospitalized.

This isn’t just poor penmanship. It’s poor practice.

How Did We Get Here?

Let’s be honest – handwriting wasn’t part of our training. We had histology slides, neuroanatomy dissections, pharmacology charts – but never a session on “Penmanship for Professionals.” So somewhere between 36-hour shifts, coffee-stained pockets, and ward rounds, our writing devolved into jagged peaks and valleys of ink that only we could read.

We also assumed that the pharmacist, the nurse, or the patient would “figure it out.” That assumption has led to fatal consequences in some cases.

The Pharmacist's Daily Struggle

Pharmacists often don’t talk about it, but many of them feel like they’re playing a high-stakes version of Wheel of Fortune. “Let’s see... C-L-A-R… is this Clarithromycin or Claritin?”
They call us. They guess. They sometimes get it wrong.

And when they do? The blame rarely falls on us.

Why Digitalization Is Not Universal (Yet)

You might be wondering: “Why haven’t we gone fully digital?”

Good question. Here are some obstacles:

• Lack of infrastructure: Many developing countries still rely on paper charts, not because they want to, but because they can’t afford EMRs.
  
  
• Resistance to change: Senior physicians who grew up on pen and paper often push back against new systems.
  
  
• Connectivity issues: In rural or underserved regions, internet reliability is spotty, making digital systems unreliable.
  
  
• Training gaps: Not every hospital staff member is trained in using digital prescribing tools.
  

But none of these are valid excuses for not writing clearly.

Writing Legibly Is an Ethical Duty

We often talk about "primum non nocere" – first, do no harm. But poor handwriting is harm. It’s an indirect, quiet kind of harm, but it adds up.

Let’s stop pretending it's charming or quirky. It’s not. It's avoidable, and in 2025, it's borderline irresponsible.

Simple Fixes Every Doctor Can Apply Today

If you’re in a country or clinic where digital prescribing isn’t yet available, here’s what you can do:

1. Write in capital letters – they're more legible.
   
   
2. Avoid abbreviations – no one is impressed by your shorthand.
   
   
3. Include full instructions – don’t assume the pharmacist will fill in the blanks.
   
   
4. Clarify dosing schedule – write “Take one capsule every Monday” instead of “1 cap q wk.”
   
   
5. Write generic names – avoid confusion with brand names.
   
   
6. Leave space between words – a crammed prescription is a chaotic one.
   
   
7. Always add your contact – so if there’s confusion, someone can reach you.
   
   
8. Double-check what you wrote – especially if you’re rushing or exhausted.
   

A Call to the Future: Prescribe Like It's 2025

We’ve already got AI that can predict disease risk, wearable ECGs, robotic-assisted surgeries – and yet we’re still handing out paper scribbles that look like kindergarten art projects?

Yes, we’re busy. Yes, we’re overworked. But sloppy writing isn’t a badge of honor. It’s a liability.

Until the whole world catches up to full e-prescribing, we must be accountable.

What If You Love Handwriting?

You can still write, just write responsibly. You wouldn't hand a scalpel to a medical student and say, “Good luck.” So don’t hand a messy prescription to a pharmacist and expect everything to go smoothly.

Use block letters. Use black ink. Spell it out.

A Final Anecdote: The Real “Risperidone vs. Ranitidine” Fiasco

Yes, this happened. A psychiatric patient was meant to get Risperidone, an antipsychotic. But the pharmacist dispensed Ranitidine, an antacid. Because of... you guessed it: messy writing.

The patient deteriorated over weeks. It wasn’t until a follow-up that the error was caught. Everyone was shocked – except the psychiatrist, who had seen his own writing and admitted, “Yeah... I can see how that happened.”

Doctors, Let’s Do Better. Let’s Write Like Lives Depend on It — Because They Do.