Anyone who has been to see their doctor and received a prescription will be familiar with how difficult it can be to decipher the long and complicated name of the medication written by your GP.

The average man on the street could be forgiven for not understanding the difference between one medication and another but it seems that this confusion over handwritten prescriptions has now spread to some in the medical profession.

A recent mix-up between a GP and a Pharmacist resulted in a female patient from Glasgow being mistakenly dispensed erectile dysfunction cream for a dry eye condition. The unnamed patient suffered a chemical injury to her eye after applying the cream. After using it the patient suffered eye pain, blurred vision, and redness along with a swollen eyelid. Luckily the injury to her eye was only mild and was treated in hospital, with the injuries clearing in a few days.

The mix up occurred after the woman was given a handwritten prescription for VitA-POS, a liquid paraffin lubrication, for treatment of severe dry eyes and corneal erosions. However, she was instead given an erectile dysfunction cream by the name of Vitaros by the Pharmacist who allegedly misread the handwritten prescription.

A report has called for all doctors to alter the way they make handwritten prescriptions by only using block capitals in an attempt to avoid future errors. Dr Magdalena Edington, of Glasgow’s Tennent Institute of Ophthalmology, wrote the report for the December edition of BMJ Case Reports.

In it, she said:

“Prescribing errors are common, and medications with similar names and packaging increase risk.

“However, it is unusual in this case that no individual, including the patient, general practitioner or dispensing pharmacist, questioned erectile dysfunction cream being prescribed to a female patient, with ocular application instructions.”

“We believe this to be an important issue to report, to enhance awareness and promote safe prescribing skills.”

As is the modern trend, many prescriptions are now digitised opposed to being handwritten but Dr Edington wants to raise awareness of the medications with similar spellings and encourage the medics prescribing these medications “to ensure that handwritten prescriptions are printed in block capital letters (including the hyphen with VitA-POS) to avoid similar scenarios in the future”.

Last year saw the release of data suggesting that GPs, pharmacists, hospitals and care homes could be making as many as 237 million prescription errors per year. Effectively, one mistake for every five drugs issued. Errors included examples such as prescription of the wrong medication, incorrect doses being dispensed and general delays in medication being administered. It is thought a quarter of these errors cause a degree of harm to the patient, that equates to just shy of 60 million.

In an attempt to reduce the number of errors being made, doctors are given guidance on their handwriting in a training manual provided by the NHS which includes exercises such as writing out the names of medication such as Ceftriaxone and Ceftazidime before asking someone outside the medical profession to read their handwriting.

The problem of doctors’ difficult-to-read handwriting is nothing new with the same training document including an example of a misread prescription which led to the death of a patient in 1995. In this instance a prescription for isordil (isosorbide mononitrate) was misread as plendil (felodipine). The patient in this instance died within a week.


At Jordans Solicitors we believe that where individuals have suffered injury caused by failings in the treatment provided by NHS and private medical practitioners, they should be compensated for their injuries. We have experienced lawyers available to provide you with advice on a range of injuries caused as a result of a delay in diagnosis, negligent treatment or negligent care, including incorrect dispensing of medications. We have offices in Dewsbury, Horsforth, Selby and Wakefield.

If you or a relative has been the victim of medical negligence and would like to consider making a claim for compensation, please contact out medical negligence team free on 0330 300 1103 or request a call back and a member of our team will contact you.

Related Blog Articles