Islamabad: Poor and often incomprehensible handwriting of doctors in Pakistan is leading to serious medication errors, including dispensing of wrong drugs, incorrect dosages, and administration of unsuitable medicines. These errors are costing lives, causing long-term health complications, and placing immense financial burdens on patients.
A senior official in the federal health ministry recalled a tragic case at a major public hospital in Islamabad where a patient died after being given the wrong medicine because of a doctor’s illegible handwriting.
“The investigation revealed that the doctor’s poor handwriting led the pharmacy to dispense the wrong drug, which ultimately killed the patient,” the official said, describing it as an example of how avoidable mistakes continue to claim lives.
Officials of the Drug Regulatory Authority of Pakistan (DRAP), senior pharmacists, and healthcare experts have termed handwritten prescriptions a “serious public health risk” and called for structured prescription guidelines and digitisation to prevent further tragedies.
A senior DRAP official said handwritten prescriptions not only create legibility issues but also lack uniformity, which often results in incomplete or unclear instructions.
“Poor handwriting can lead to misinterpretation of medication names, dosages, or instructions, increasing the risk of dispensing wrong drugs. Similar-sounding medicines, often known as look-alike and sound-alike drugs, are especially dangerous when written unclearly. Such prescriptions are also prone to forgery, cannot be tracked in electronic systems, and delay treatment when pharmacists have to reconfirm details with the prescriber,” the official warned.
Former federal health minister and renowned infectious disease specialist Dr. Faisal Sultan said the issue goes beyond bad handwriting. “It is the need to have structured elements of a prescription that must be filled out, ideally on a phone app or an online platform,” he explained. According to him, a proper prescription must carry prescriber details, patient information, exact drug specifications, dosage, route of administration, treatment duration, clear instructions to patients, and dispensing details for pharmacists. “Ideally, this should be done on a pre-printed form or an online portal to eliminate ambiguity, prevent omissions, and ensure patient safety,” he stressed.
The absence of qualified pharmacists in hospitals and pharmacies is compounding the problem, experts said. Without trained professionals reviewing prescriptions, errors remain unchecked. Wrong drugs are dispensed, patients are sometimes told to break tablets inappropriately, and dangerous drug interactions go unnoticed. “When pharmacists are involved, they can cross-check prescriptions, verify dosages, counsel patients, and intervene in case of errors. Unfortunately, in Pakistan, doctors often resist such interventions, even though the same doctors follow pharmacist checks when practicing in Europe or North America,” a former DRAP chief observed.
He added that many prescriptions are written without proper screening tests, while drug-drug interactions and polypharmacy — prescribing multiple drugs with overlapping effects — have become common. “Some tablets are coated for safe absorption, but patients are wrongly advised to break them in half when the correct concentration is unavailable. Such mistakes can render the medicine ineffective or even dangerous,” he said.
Highlighting systemic gaps, Abdul Latif Shaikh, President of the Pakistan Society of Health-System Pharmacists, said medication errors occur at several points in the healthcare chain. “The first major error originates at the prescribing stage by the physician, followed by transcription errors by nurses or health workers. When prescriptions are not reviewed by pharmacists, adverse events multiply. This is why pharmacist oversight is critical, as it can reduce morbidity, mortality, and costs associated with medication errors,” he maintained.
Globally, even in countries with advanced health systems and strong pharmacist interventions, medication errors contribute to thousands of deaths annually. In Pakistan, where pharmacovigilance systems are nearly absent and reporting of errors is rare, the risks are far greater. Wrong drug dispensing, confusion due to similar-sounding names, absence of screening for patient sensitivities, and lack of prescription audits remain widespread, experts warned.
Health professionals agree that the solution lies in a combination of regulation, digitalisation, and stronger pharmacist presence. They recommend that Pakistan move toward mandatory e-prescriptions, backed by structured formats, to standardise drug orders and integrate them into electronic health record systems. “This is not just about fixing handwriting. It’s about creating a safe, transparent, and fool-proof system that protects patients from preventable harm,” Dr. Faisal Sultan concluded.
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