Dhaka, Banglaesh || Sunday, 5 April 2020 || 20 Choitro 1426
Department of Public administration Stamford University Bangladesh
“Carelessly written prescriptions by Bangladeshi doctors can cause dangerous physical damage for patients and sometimes even leads to death”
Md: Anamul Haque Mridha
Published : Saturday, 21 March, 2020 at 9:32 PM, Update: 21.03.2020 9:54:42 PM, Count : 179

“Carelessly written prescriptions by Bangladeshi doctors can cause dangerous physical damage for patients and sometimes even leads to death”

“Carelessly written prescriptions by Bangladeshi doctors can cause dangerous physical damage for patients and sometimes even leads to death”

THIS PAPER PUBLISHED IN INSEARCH -2019: 6TH INTERNATIONAL INTEGRATIVE RESEARCH CONFERENCE ON GOVERNANCE IN SOCIETY, BUSINESS AND ENVIRONMENT.

Abstract
It is known to all that the prescriptions given by doctors are mostly obscure to the commoners. In some cases, even the workers in pharmacies fail to comprehend what is written in the prescriptions. As a result, they provide wrong medicines which is causes physical harm to the patients for whom they were prescribed. The hand writing of the doctors should not be obscure because it might lead the pharmacist to prescribe wrong medicines. It often happens that when the writing is obscure the pharmacists provide the medicine that sounds close to that prescribed by the doctor.  Objective of this paper describe concisely, Bangladeshi doctors handwriting should not be obscure. By doing we can be exposed to various health risks. This problem can be solved by creating awareness among the lower classes to upper classes of the society for that regard.  Patients, included doctors needed concern about obscure handwriting. This paper is an applied research paper, primary data and also secondary used for this. I have conducted a survey on online and come to know from analyzing the experience of 120 people online and from meeting 100 people in a body.  It was found that almost everyone had such experience of bad hand writing of doctors.   It is highly deplorable that a country cannot guarantee a 100% medical facility moreover people are victimized by obscure hand writing of doctors. It is a great surprise that for a country like America 7000 people annually and 1.5 million people suffer from various physical complications and it is all due to the bad hand writing of the prescriptions. At present, the literacy rate in Bangladesh is 72.9%.  However, the rest 28 percent are uneducated.  Therefore, they face grater problems because they cannot even read themself like the educated people.  Who will think of the rest 28% population?  The prescription of doctors remain obscure mostly the illiterate people and it is mostly in village than in cities, that people facing problems with obscurity of prescriptions. It would be wrong to assume that this problem occurs in Bangladesh.  In fact, even in the developed country this problem is acute and it’s a professional problem of doctor’s present worldwide. Therefore, in many countries writing prescription have become digitalization, So that people don’t misunderstand or have difficulties with understand the prescription.  As it is not possible, to ensure good hand writing of doctors.  So this alternative approach is applied.  The method is starting to be applied in Bangladesh, but many doctors cannot apply is as it is costly and materials are not easily available.  We should be more careful about this problem so that no more people endangered physically.
Key Words: - Obscure, Experience, Complications, Assume, Digitalization, Endangered

Introduction
Doctors are often typecast for their bad handwriting. Even in the Bangladesh, it is broadly profess that the prescriptions they give their patients are either confusing or illegible. The fact that the doctors’ handwriting is provide illegible and can lead to more severe threats and health damage.

In spite of the computer rising, much information in clinical records continues to be handwritten. The author may understand what has been written, but difficulties can come to light when other parties are intricate. This is accepted that doctors have illegible handwriting. The writer generally wit what is written, but when other parties are engaged they often have problems reading and ascertain the text. The following quote stresses the problem with illegible handwriting: ‘Doctors’ sloppy handwriting kills more than 7 000 people annually.’ An example of this was found in the British Medical Journal where it was reported that a 42-year-old American died after the pharmacist issued Isordil® which he interpreted as Plendil® as a result of the doctor’s illegible handwriting.

Research Question
The research question of this paper is as follow;  
What are causes and consequences of carelessly Written Prescriptions by Bangladesh Doctors?  
What are the consequences of high court orders not implementing?

Research Goal
To recommend a framework which will ensure proper implementation of high court order, and increase awareness among doctors also patient.
Objective of the study:
To Doctors should be emphasizing now, to write a clear prescription
To find out enough reasons behind doctors' bad handwriting
To Creating awareness among the lower to upper classes of the society
To hold the provisions of punishment by the government
To ensure proper implementation of high court order
To strongly follow high court order, otherwise punishment for that. 

Conceptual framework
At present, the literacy rate in Bangladesh is 72.9%.  However, the rest 28 percent are uneducated.  Therefore, they face grater problems because they cannot even read themself like the educated people.  Who will think of the rest 28% population?  The prescription of doctors remain obscure mostly the illiterate people and it is mostly in village than in cities, that people facing problems with obscurity of prescriptions. It would be wrong to assume that this problem occurs in Bangladesh.  In fact, even in the developed country this problem is acute and it’s a professional problem of doctor’s present worldwide.
Review of related literature:

Proper prescription writing
Proper writing of prescriptions involves abiding by a strict format to assure its completeness and specificity. This format includes the 
(1) Superscription,
(2) Inscription,
 (3) Subscription, and 
(4) Transcription.
Superscription is the part where the date of prescription, name, age and other details of the patient, and the symbol Rx can be seen. Inscription is the body of the prescription, where the name and amount of medicine is indicated. The directions to the pharmacist are placed under subscription, while directions for use and other notes fall under transcription. The prescriptions that will be used in the study will include all parts but the superscription. All doctors will be asked to follow the same format, and write all necessary details to assure the accuracy, and consistency, and also to assure that all the mistakes and misinterpretations from the prescriptions can only be attributed to the legibility of the handwriting of the doctors.(Cerio, Mallare, & Tolentino, 2015)

The use of certain abbreviations are still practiced in writing prescriptions, but these actually arise to even more confusions and misinterpretations. A comprehensive list of abbreviations and proper writing of directions, dosages and further instructions will be referred to from past researches. In this study, the ideal abbreviation formats and direction syntaxes will be applied to make sure that the doctors and those who will be interpreting the prescriptions are fully aware of the standards and will not be committing errors from the misuse of abbreviations.(Brits et al., 2001)

Common prescription errors
A medication error is referred to as any preventable event that may cause inappropriate medication use that can pose harm to the patients. It is by recognizing these possible errors that suitable ways can be found to prevent them.

Common medication errors cover the writing of prescriptions, transcribing these prescriptions, and administering the medications. Of these errors, majority is attributed to the writing of prescriptions, and this is rooted mainly to the illegible handwriting of the doctors
 In writing the prescriptions, the use of abbreviations and other shortcuts, incomplete or unclear directions, and missing or unordered details and use of nonstandard nomenclature are what constitute the mistakes. In this study, the possibilities of these errors are eliminated by using the ideal syntax and properly abbreviating terms and directions for use. It has also been prior noted that a standard format will be followed to eradicate confusions in the order of prescription details.(Brits et al., 2001)

A scientific gathering called the National Summit on Medical Abbreviations was conducted in 2004 to gather medical practitioners from different disciplines and discuss the standards that will have to be followed to significantly reduce the number of casualties caused by improper use of abbreviations, acronyms and symbols. From this convention, several ambiguities were cleared and standards were revised to accommodate these changes (Rodríguez-Vera, Marín, Sánchez, Borrachero, & Pujol, 2002)

By accounting for these common errors, the cause of misinterpretations can be narrowed down to the readability of the doctors’ handwriting. This can range from an illegible penmanship, to the misreading of symbols especially writing down digits or other measurements.

The use of decimals and placements of zeros may cause confusion in interpreting numerical data. Some may use 1.0 to indicate 1, where the decimal point may not be emphasized enough which then cause dosage to increase tenfold. These types of errors are easily committed, but have very adverse effects on the patients.(Akoria & Isah, 2008)

The latest salvo from the Medical Council of India (MCI) insisting on legible handwriting of doctors is admirable, though much delayed. This directive is expected to reduce the number of potential medical errors that occur due to illegible handwriting and spelling mistakes. Poor handwriting undoubtedly contributes to a high incidence of medical errors. In Britain, medical errors were estimated to cause deaths of up to 30 000 people per year and in the USA up to 100 000 per year. Other authors have cautioned that illegible handwriting in prescriptions may lead to fatal consequences4 and is a leading cause of medication error.(Paper, 2003)

How many such errors happen in India, where English is not the primary language of doctors, is anybody’s guess. How many such medical errors were due to illegible or wrongly spelt prescriptions is also not known. 

The joke doing the rounds since centuries is that a person with illegible handwriting will become a doctor! Sometimes doctors themselves cannot read their own handwriting, though they sheepishly admit it to be their own. The most common reason for illegible handwriting is the large number of patients to be seen, notes to be written and prescriptions given, in a short time. It should also be accepted that poor handwriting has no correlation with the medical acumen or expertise of a doctor. A prospective controlled study showed that doctors have handwriting no worse than that of group of other healthcare personnel and much better than that of healthcare executives.in another study across occupations, no differences in legibility were observed even after adjustment for age and education. In all, 40% of men’s handwriting was illegible compared with 20% of women’s. A surprising finding of another study was that poor legibility was confined to letters of the alphabet rather than numbers. This may reflect the importance attached by doctors to legibility of drug doses, but not names.(Rodríguez-Vera et al., 2002)

For each prescription, the name of the medication, medication strength, and dosage, and dosage interval, route of administration and duration of treatment were checked. Omissions on the prescriptions were also noted. Each drug on the prescription was interpreted separately. If more than five items were written on prescription, only the first five were included in the study for logistical reasons. Data were coded according to a system where

‘0’ was given for an incorrect reading and ‘1’ for a correct reading.

The present study clearly demonstrates that perceived illegibility of handwritten medical records significantly varies according to both the specific occupation of the healthcare stakeholder, as well as their relative level of clinical experience. Although respondents were asked to make their decision on legibility of a sample based on legibility as opposed to comprehension of sample content, clinical experience had a notable effect on legibility ratings. This relationship might be explained in terms of a putative relationship between greater clinical experience and increased practice in deciphering poor handwriting. Alternatively, studies inhuman cognition would suggest that increased familiarity with a word and the context of its use reduces the necessity that every letter be legible in order to interpret a word’smeaning.12 Simply put, greater familiarity with a word and greater understanding of its clinical context improves the ability to read it.(Murray, Boylan, O’Flynn, O’Tuathaigh, & Doran, 2012)

It is possible that some changes resulting from the educational intervention may have been obscured by attrition in the numbers of doctors. The better response to educational intervention seen in private hospitals (evident in increased numbers of doctors who included the doses and routes of drug administration) could be due to the fact that doctors in private hospitals have fewer exposures to such educational sessions, and therefore responded more readily than their colleagues in public hospitals. This may give credence to the suggestion that familiarity with an intervention method reduces its effectiveness.(Bruner & Kasdan, 2001)

Methodology 
As the study deals with critical public health issue, the researcher conducted the collection of data for the period of 6 months in a mixed method way using semi structure questionnaire. A sample of 220 respondents were decided for collecting data from urban area, the sample were all educated as to provide the actual data knowing the sensitivity of the issue. Every respondents were above teenage as to understand the depth of the topic, urban area was selected as to enhance the possibility of finding more concentrated patient. The source of data was primary for obvious reason.  

This study consisted of two major parts. In part one what are the consequences of high court orders not implementing? And another is, the rest 28% percent are uneducated people in our country.  Therefore, they face grater problems because they cannot even read themself like the educated people.  Who will think of the rest 28% population?  The prescription of doctors remain obscure mostly the illiterate people and it is mostly in village than in cities, that people facing problems with obscurity of prescriptions.


Source Data collection method Sample size Age group Area Type of questionnaire Soft wear Duration
Primary mixed 175 Adult urban Semi-structure SPSS 9.0 6 months


Research Design
The study was conducted in Dhanmondi area from June 10, 2019 to November 30, 2019. As well as contributing factors, impacts, and responses at individual and institutional levels. Quantitative data were collected through questionnaires. Independent interviews and focus group interviews were manage to obtain qualitative data.   

Population and Sample  
The research setting in this study is Dhanmondi area, Dhaka. In Dhanmoni, there is a wide variety of health care services, including all the types of services and levels of health care, Doctors chamber, huge model pharmacy. I have conducted a survey on online and come to know from analyzing the experience of 120 people online and from meeting 100 people in a body. 

Research Tools
Questions for focus group discussions and in-depth interviews, as well as questionnaire provided by researchers. After that, one specialist in the English language edited the questionnaire. 3 teacher were invited to evaluation the questionnaires. Some terms and word were adapt according to their suggestions.

Data Collection
Data were collected between Junes to November.2019. Qualitative data were collected through focus group and in-depth interviews, throughout the processes of qualitative data collection. Most of the locations for focus group interviews were the road side, in front of pharmacy on Dhanmondi area, the workplace of the researchers.  
 
For the quantitative data, the researchers the purpose of the research project as well as the techniques and procedures for questionnaire survey were explained.

Scope and limitations
The study is limited to respondent patient and to comprise the prescription, error-prone drugs, abbreviations and symbols in prescriptions were collected based on related literature and were divided into prescription components (medicine name, numbers, abbreviations, and text). Reviewer will only include people from contrasting age groups, and pharmacists who Distribute medicines in drug stores. 
Feedback specify that many subjects felt that the questionnaires were a little bit long. It was perceptible in the returned questionnaires that some questions in the final parts were not answered.

Data Analysis
Collection data by questionnaire and survey. Categorized qualitative style, were analyzed by the SPSS 9.0 software program. Descriptive statistics is accompany the demography characteristics of the sample. The differences of the responder opinion are measure by some other theory process. Descriptive statistics was employed to illustrate the demographic characteristics of the sample. Qualitative data were analyzed by content analysis by varies table. 
Demographic Characteristics of the Sample

Responded ratio Based on Gender
 
Graph 1: Responded ratio here Male 65% & Female 35%

Demographic characteristics of the sample are draw in Graph 1. Sample size was 200 but 174 responded are answered to questionnaire by online and face to face interview.  The majority of the sample were Male (69.7 %), aged (adult, 100%).There were non-significant differences in the age and between males and females. The majority of male subjects were aged. I made a decision because of adult person are responsible to guide doctors activates. 
Educational Status of Responded

 Graph 2: Responded education ratio 7% illiterate & 93% educated  

The literacy rate in Bangladesh is 72.9%.  However, the rest 28% percent are uneducated.in here my responded ratio where 7% are illiterate and 93% are educated. My research was held on urban area. 37% people are victimized by obscure hand writing of doctors in Bangladesh. For that case, Bangladeshi doctors can cause dangerous physical damage for patients and sometimes even leads to death.

CAUSES OF BAD HANDWRITING 
Unreadable handwriting causes loss of information and prevents better care for patients.  I believe that Mahatma Gandhi’s belief that ‘good handwriting is an asset’, is applicable to physicians maybe more than most other professions. A doctor’s handwriting can mean the difference between life and death for patients. Can there be any asset beloved than life, which doctors protect? And if the doctor’s handwriting can clear the patient of that protection, isn’t good handwriting an invaluable asset for doctors? Shouldn’t all doctors then attempt to obtain such an asset? My answer is an unequivocal ‘YES’.

Written connection is of great importance in medical practice and unreadable handwriting may cause serious problems unreadable handwritten prescriptions are well-recognized for enlarge the risk of medicine errors, including prescribing, distribute, and administration. 
If you’ve eternally taken a handwritten prescription from a doctor or looked at the notes from your visit, it seems like no amount of squinting could help the letters get clearer. It’s not like only people with bad handwriting are related to the medical field.

Doctors’ prescription isn’t just a conductor for patients but also a direction manual for family members, testimonial of drug requirement for chemists and track record of patients’ past and present conditions for other doctors.

? Obsessive writing is bad writing
      For one thing, doctors have to write more than just about any other job

? Hurry takes a Levy 
 If doctors could spend an hour with every patient, they might be able to slow down and give                                      their hands a rest. But the fact is, most physicians are rushing around to the next patient.

? A weighty workload set the doctors under
      Oppression.
? Prescription structure blanks were not always
      Accessible
? Some patients decline to give true personal
      Details about disease and also age and address.
? Doctors are untaught of the standards required in a good prescription order.

? Limpidity where it matters 
? Disorientation
? Deliberately poor calligraphy 
? Multiple mental images 
? Inadequate natural orientation

Causes of high court orders not implementing
High court has formed a petition that doctors will have to write prescription with well understandable hand writing. Still we see doctors are not very aware of it. We often see doctors are writing prescriptions with unclear hand writing. Lacking:
1. Doctors are not aware of their non-understandable hand writing and patient's sufferings. 
2. Their unprofessionalism and being not respectful to the law. 
3. Government has zero monitoring in this field whether doctors are following the laws or not.
4. We do not see any action by the Public Health Administration like black listing or issuing any charge like suspension.
5. Victims (patients) do not raise their voices and their unawareness.

CONSEQUENCES OF BAD HANDWRITING 

In past, doctors doodle notes to keep a personal record of the patient's medical history. The notes were normally seen only by the doctor. Today, doctors are no lengthy one-man bands. With dozens of other professionals, doctors are but one component of a large, collaborative health care team. A consequence of this expansion is that illegible scribble, quickly composed by rushed doctors, and are now presented to colleagues with no qualifications in cryptology.
From this study perspective, illegible handwriting can delay treatment and lead to unnecessary tests and unsuitable doses which, in turn, can result in irritation and death. There are many ways by which illegible documents, signatures, and prescriptions Result in a lower quality of health care. These include lost time and money, medicine errors, inefficient or faulty communication. 
Our doctor community can’t follow High Court order which are issued on 9th January, 2017.
In the matter of:
An application under article 102 of the constitution of People’s Republic of Bangladesh, to take appropriate and effective steps to issue prescription for the patient in capital letters in “legible” manner or printed way by the doctor’s and also mention the genetic names of the drugs so as to ensure right medicine to the common people . 

? Bad handwriting Prescription Waste of Professional Time. 
? Bad handwriting Prescription Can Result in Medication Errors.
? The Dangers of Misinterpretation are Greater When the Physician Signature is sloppy.  
? Bad Handwriting in the Medical Field is Costly.
? Bad handwriting Prescription Documents Fail to Communicate Important Information. 
? Bad handwriting Prescription Create Potential Legal Problems. 

Recommendation 
Not every single doctor who enters medical school is biogenetic pre-establish to have poor hand writing. The complication lies with the arrangement. There have been many suggest tincture from the very uncomplicated to the complex and cheap. Like simplest solutions is, if not the most general solution, is to print and to avoid potentially mystify abbreviations.
Digital solutions are almost without limit. Among them are dictation systems for all prescriptions, letters, notes, and orders; computer order entry; and typed, pre-printed prescription pads and order pages for computer generated prescriptions.  Many solutions of varied cost and scope, but the trouble does exist. Poor, sloppy handwriting of prescriptions, orders, records, and signatures imperil patients and importantly let down the standard of care. 
In the near future, the entire activity may change with digital prescriptions and digital records going straight to the pharmacy and chemists from the doctor’s computer, which will take care of poor handwriting of doctors and reduce perceptible medical errors and difficulty.  Doctors and hospitals already use digital prescription, which go digitized, directly to the pharmacy. Also, technology today allows for oral prescriptions and notes, which can be write out, or transform to digital ones with suitable software for speech to text put in writing.

Training of doctors
Doctors have sloppy handwriting mostly when they are in a rush when writing prescriptions. This rush in writing happens regularly during their rounds, or in peak hours, or if subjected to tiredness. Training will have to be provided to decrease mortality because of ill calligraphy. The trainings should begin in the onset of their medical career, or even premature.


Evaluate groups
A plan of action can be outline when it comes to writing prescriptions that can be easily apprehend by everyone, of all ages and sectors, so that the errors in reading and elucidate medical prescriptions can be stop. On the part of the pharmacists, the Department of Health can inflict a rule in which all drugstores, local or national, must only hire a licensed pharmacist who would administer all drug distribute. Since all evaluate groups demonstrate to consistently yield average to high error counts, the defect lies in the prescription itself. It would necessitate changing the prescription procedure, remarkably upgrade the doctors’ handwriting, or improve modify computerized prescription system.

Element of Prescription  
Found out in this study that short-form/abbreviations contributed the most to the errors in the prescription judgment.
The use of short-form/abbreviations should be disallow in writing prescriptions because they cause more uncertainty mostly to those who are not intimate with it. Use of short-form/abbreviations will necessitate training and acquaint the patients, nurses, pharmacists, and doctors with these. Doing this will suffer huge costs in organizing classes or campaigns to promote familiarization, so a more efficient elimination system would be avoiding short-form/abbreviations and shorthand, and spelling everything out in prescriptions.


Awareness 
Most important things is awareness between doctor’s and also patient. Several details that are required for the recognition of patients as well as prescribers were absent, and the majority of prescriptions were not clearly readable. 
Our Bangladeshi doctor’s also maintain High Court ruled which petition are declared 9th January, 2017. But couldn’t any monitoring cell are not proper follow up this High Court Order , and another sad news that many people aren’t know about this special jurisdiction petition. 

Digitalization of Prescription 

The Digitalization of medical prescription starts with the input made on the stylus by doctors. This writings are read as an image. Image is undergoing preprocessing using opens functions. The aim of pre-processing is to eliminate the inconsistency that is inherent in cursive handwritten words. In pre-processing we will get separate medicine names from the whole dataset. 

Conclusion
The prescription of doctors remain obscure mostly the illiterate people and it is mostly in village than in cities, that people facing problems with obscurity of prescriptions. It would be wrong to assume that this problem occurs in Bangladesh.  In fact, even in the developed country this problem is acute and it’s a professional problem of doctor’s present worldwide. Therefore, in many countries writing prescription have become digitalization, So that people don’t misunderstand or have difficulties with understand the prescription.  As it is not possible, to ensure good hand writing of doctors.  So this alternative approach is applied.  The method is starting to be applied in Bangladesh, but many doctors cannot apply is as it is costly and materials are not easily available.  We should be more careful about this problem so that no more people endangered physically.


Reference

1. Akoria, O. A., & Isah, A. O. (2008). Prescription writing in public and private hospitals in Benin City, Nigeria: The effects of an educational intervention. Canadian Journal of Clinical Pharmacology, 15(2), 295–305.
2.Brits, H., Botha, A., Niksch, L., Terblanché, R., Venter, K., Joubert, G., … Kasdan, M. L. (2001). Illegible handwriting in medical records. The Journal of the Kentucky Medical Association, 18(2), 189–192. https://doi.org/10.1258/cr.2012.011065
 3.Bruner, A., & Kasdan, M. L. (2001). Handwriting errors: harmful, wasteful and preventable. The Journal of the Kentucky Medical Association, 99(5), 189–192.
 4.Cerio, A. A. P., Mallare, N. A. L. B., & Tolentino, R. M. S. (2015). Assessment of the Legibility of the Handwriting in Medical Prescriptions of Doctors from Public and Private Hospitals in Quezon City, Philippines. Procedia Manufacturing, 3(Ahfe), 90–97. https://doi.org/10.1016/j.promfg.2015.07.112
 5.Murray, S., Boylan, G., O’Flynn, S., O’Tuathaigh, C., & Doran, K. (2012). Can you read this? legibility and hospital records: A multi-stakeholder analysis. Clinical Risk, 18(3), 95–98. https://doi.org/10.1258/cr.2012.011065
 6.Paper, W. (2003). A Case Study in Thailand.
 7.Rodríguez-Vera, F. J., Marín, Y., Sánchez, A., Borrachero, C., & Pujol, E. (2002). Illegible handwriting in medical records. Journal of the Royal Society of Medicine, 95(11), 545–546. https://doi.org/10.1258/jrsm.95.11.545











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