Doctor's bad handwriting caused fatal prescription mix-up, jury finds.

A Texas jury's recent verdict in a medical negligence case offers a lesson for doctors that they should have learned in grade school: Penmanship counts.

The state court jury in Odessa awarded compensation to the family of Ramon Vasquez, who died after a pharmacist misread a prescription for heart pain medication written by Vasquez's cardiologist. (Vasquez v. Albertson 3, Inc., No. A-103,042 (Tex., Ector County Dist. Ct. Oct. 19, 1999).)

"I think that every doctor who hears about the verdict will take a moment to try to write more clearly," said B. Kent Buckingham, a Midland, Texas, lawyer who represented the plaintiffs.

Vasquez, 42, who had a history of heart problems, was seen by cardiologist Ramachandra Kolluru, who prescribed Isordil for heart pain. The prescription instructed Vasquez to take 20 milligrams of the drug four times a day.

When Vasquez took the prescription to be filled, the pharmacist read it as an order for Plendil, a drug used to treat high blood pressure. Although Plendil has a recommended maximum daily dose of 10 milligrams, the pharmacist filled the prescription with directions to take the drug at the dose Kolluru had prescribed for Isordil. So, Vasquez not only received the wrong drug, but he was told to take it at eight times its recommended maximum daily dosage.

After taking several doses, Kolluru became ill and went to a hospital emergency room where doctors determined he had suffered a heart attack. He died two weeks later.

Prescription mix-ups like this are a common problem, according to Michael Cohen, the president of the Institute for Safe Medication Practices in Philadelphia. "We get several thousand reports [of prescription errors] each year, and 25 percent are related to drug names that are mixed up," Cohen said.

Part of the problem is the influx of new drugs on the market. In the past decade, the number of trademark applications for prescription drugs has quadrupled, Cohen said. This has made it harder for drug manufacturers to come up with names for new drugs.

"There are now 13,000 prescription drugs on the market," Cohen said. "It's a challenge for the pharmaceutical industry to find a name that is catchy but that does not sound or look like something else."

Sound-alike/look-alike drugs--like the pain medication Celebrex, the antidepressant Celexa, and the antiseizure drug Cerebyx --can be easily confused, Cohen said. In July, his organization issued an alert asking the makers of Celebrex--Searle/ Pfizer--to consider changing the drug's name. Although that hasn't happened yet, the companies have run ads in medical journals warning doctors to take special care in prescribing the drug. (Rick Weiss, Thousands of Deaths Linked to Medical Errors, Wash. Post, Nov. 30, 1999, at A1.)

A recent study by scientists with the National Academy of Science's Institute of Medicine reported that as many as 98,000 Americans die each year from medical mistakes and that most of these mistakes involve medication errors. The study included several recommendations to reduce medical errors, including requiring drug makers to test potential drug names--using FDA-approved methods--to reduce potential sound-alike and look-alike confusion with existing drugs.

Health care practitioners are being urged to be more careful, too, Buckingham said. "I have actually heard from a number of physicians who have called me out of the blue to say they have harped on colleagues for years about [handwriting] and that they are now using [the Vasquez verdict] as a tool to convince them to write clearly." Buckingham said he has also heard that several medical organizations have issued bulletins warning doctors to write legibly so prescriptions and medical records can be easily read.

Cohen agrees that better penmanship would help. He said doctors should also write the patient's diagnosis on the prescription so pharmacists would be able to see what the drug is being used for.

And, Cohen said, doctors should take advantage of new technology. "Some doctors are now using handheld devices, like Palm Pilots, to write out prescriptions, which are then printed out in the doctor's office or sent electronically to a pharmacy. It's time to go electronic," he said.

"Changes like these could make all the difference," Cohen said. In cases like that of Ramon Vasquez, it could be the difference between life and death.

The full text of the Institute of Medicine's report, To Err Is Human: Building a Safer Health System, is available on the National Academy Press Web site at http:// www.nap.edu/books/0309068371/html/. To purchase a prepress copy for $45, call the Academy Press Customer Service number at [phone].