In our Legal Issues in Medicine column, we described a malpractice case involving a nephrologist who started writing a prescription for 10 mmol of potassium when he was interrupted.
When he returned to writing out the prescription, he rethought the dosage and decided to make it 20 mmol instead. Rather than start with a fresh prescription or cross out what was already written, the doctor attempted to write a “2” over the “1.” A nurse and a pharmacist misread the prescription, which was filled for 120 mmol. Within 12 hours, a patient died as a result.
In light of the fact that doctors today have available alternatives to handwritten prescriptions, such as electronic prescribing, Renal & Urology News would like to ask urologists and nephrologists the following poll question.