A handwritten doctors’ note is the frequent butt of jokes, but a new medical case study is showing how this old cliche could potentially spell real danger for patients.
A woman in Scotland was inadvertently made 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 somewhat easy to see how the gaffe came about. The erectile dysfunction cream is called “Vitaros” and the ocular lubricant is called “Vit-APOS.” The error was not spotted by the GP, pharmacist or individual patients, so she purposed up applying the cream to her eyes.
The active ingredient in the erectile dysfunction cream is alprostadil, a naturally occurring compound that distends blood vessels. When applied to the skin( or, you are familiar with, the penis) it will increase blood flowing to the area. Nonetheless, as you can imagine, it can acutely irritate the eye.
Fortunately, she made a full recuperation with some simple therapy of topical antibiotics, steroids, and lubricants, but the mild chemical trauma still made her to be victims of 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 reasoning: “It is unusual in this case that no one is( including the patient, general practitioner or dispensing pharmacist) questioned erectile dysfunction ointment being prescribed to a female patient, with ocular application instructions.”
The study authors say they believed this was an important issue to raise in a case study, to promote awareness and safe prescribing skills. These various kinds of corrects happen a surprising quantity, occasionally with deadly results. Last year, a report found that health professional in England make around 237 million prescription screw up each year, such as furnishing patients with the wrong drug or prescribing the incorrect dose. It even suggests that these corrects are responsible for 700 deaths per year, and used to play a significant factor in the deaths up to 22,300 others.