January 12, 2013: Change to Handwritten Prescription Leads to Dose Misinterpretation
A physician wrote a medication order for a patient who needed analgesia for pain.After writing the prescription for “morphine 1 mg ”, the physician changed the order by writing the number “2 ” over top of the “1 ” in the dosage. As a result, the order was misinterpreted as “morphine 8 mg”. The patient received several doses at quadruple the intended amount before the error was identified and corrected. The patient did not experience any harm, although additional monitoring was required.
Whenever information in a handwritten communication (e.g., a prescription or a transcription) must be altered, it is best to cross out the incorrect information and start over.
