Handwriting on the wall?

From the July 16,1997 Issue

We recently learned about a case in which the physician, the pharmacist and the pharmacy are all being sued for damages as a result of a death. The patient received a prescription for Isordil® (isosorbide dinitrate) 20 mg q 6 hours. However, the physician's handwriting was illegible, and the pharmacist misread the prescription with Plendil® (felodipine). After taking the medication for a day, the patient suffered a myocardial infarction and died a few days later. According to the plaintiffs, reasonable standards of medical and pharmaceutical care were not provided by the physician, the pharmacist or the pharmacy.

Fig. 1. Poorly written prescription for Isordil seen as Plendil

Plaintiffs' attorneys are beginning to appreciate the systemic nature of medication errors. In particular, in this case they recognized that the physician wrote poorly and the indication was not included on the prescription. The pharmacist was named in the suit because he did not question the illegible prescription or the high dose of Plendil (maximum dose 10 mg daily). The pharmacy itself was also named in the suit because it failed to incorporate controls that could have prevented the error. For example, the pharmacy computer did not catch the excessive dose.

Certainly, physicians and pharmacists have been sued in civil court for errors in the past. However doctors are usually sued if the wrong medication was due to misdiagnosis while pharmacists usually bear the brunt of the blame for dispensing the wrong product. Whatever transpires with this case, it could set a new standard of practice.