Error-Prone Abbreviations and a Badly Drafted Complaint Reply
A 68-year-old man with advanced cancer and severe back pain attends the OPD pharmacy of a Delhi government hospital with a hand-written prescription from a visiting oncologist. One line reads: "Tab MS 10 mg BD". Lower down, on a separate slip issued for a diabetic relative, the prescription reads "Inj Insulin 10 U s/c", and the "U" is written so carelessly that it looks like a zero. The prescription carries the doctor's registration number but no diagnosis, no weight, and no route or duration for the tablet. The patient's attendant says the doctor told them it was "the strong painkiller, twice a day". That same morning the patient's son submits a complaint letter about a 40-minute wait at the counter. Your junior has drafted a reply that begins: "Your complaint is not valid because the crowd was heavy and you should have come early." The hospital follows ISMP guidance on error-prone abbreviations.
1. Identify every ambiguous element in the prescription, state what you would do before dispensing anything, and note the record-keeping consequence for the tablet.
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Ambiguities, and why each is dangerous.
- "MS" may mean morphine sulfate or magnesium sulfate. Magnesium sulfate is not given orally at 10 mg twice daily for pain, so morphine is the likely reading - but likelihood is not authority. This is a documented source of fatal error.
- "10 U" on the insulin slip is the classic "units" hazard: a trailing U read as a zero turns 10 units into 100 units, a tenfold overdose of insulin. It must be written as "10 units" in full, never abbreviated.
- Missing information: no route, no duration, no diagnosis, no weight for a frail elderly patient, and "BD" left as an abbreviation rather than "twice daily".
Action before dispensing. Do not guess and do not "dispense with a verbal note". Telephone the prescriber, read back the full drug name, strength, route and frequency, record the name of the person spoken to, the time and the clarification in the prescription record, and have the prescriber amend the prescription in writing or issue a fresh one. If the prescriber cannot be reached, the prescription is held, not filled. Counsel the attendant on the difference between the two drugs so the same confusion does not recur at home.
Record consequence. Morphine is a Schedule X drug: the prescription is retained in duplicate, one copy being kept by the pharmacy for the statutory period, and the supply is entered in the narcotics register with patient details, prescriber details and quantity. Dispensing on an unresolved abbreviation would corrupt that register permanently.
2. Rewrite the medicine label and the spoken instructions for this patient so that an elderly man with no English can act on them correctly.
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Label (after the prescriber has confirmed the drug and dose):
MORPHINE SULFATE 10 mg tablet Take ONE tablet by mouth, TWICE a day (morning and night). For pain. Do not take extra tablets for breakthrough pain unless the doctor has prescribed a separate medicine. Causes drowsiness and constipation - avoid driving; report severe drowsiness or slow breathing immediately. Keep locked away and out of reach of children.
Spoken counselling, in the patient's own language, using teach-back. Say the frequency as "morning and night", not as "BD"; say "one tablet", not "10 mg"; say "by mouth", not "PO". Then ask the patient or attendant to repeat back when the next dose is due and how many tablets make a day's supply. Only when they can state it correctly is the counselling complete.
Reasoning. The original label carried an abbreviation the patient could not act on, which is precisely how a correct prescription becomes an incorrect dose at home. Labels fail at the point where the reader cannot decode them, not at the point where the pharmacist writes them. Teach-back converts a label into behaviour, and it also reveals comprehension problems that a simple "do you understand?" never will.
3. Identify the faults in the junior's draft reply and rewrite it as a short, professional response.
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Faults in the draft.
- It rejects the complaint before acknowledging it; a 40-minute wait in a hospital pharmacy is a legitimate service concern, and the patient's son is reporting a fact, not an opinion to be argued.
- It blames the complainant ("you should have come early"), which is both discourteous and outside the facts - no opening time was ever communicated to him.
- It offers no explanation, no remedy and no next step, so it closes the conversation without resolving anything.
- "Is not valid" is a legalistic phrase that reads as hostile in a public hospital setting.
Rewritten reply.
Dear Sir, Thank you for writing to us about the delay at the pharmacy counter on 12 June. We are sorry for the inconvenience caused to your father. Our records show that the counter received an unusually heavy OPD load that morning, and the prescription also required a clarification from the prescriber before it could be dispensed, which added to the waiting time. We have now arranged for a second dispensing point during the peak hours of 9 a.m. to 12 noon, and we are reviewing our token system so that elderly patients are not left standing. If your father needs a repeat supply, please ask for the duty pharmacist, who will assist him directly. We would be glad to hear from you again. Yours sincerely, Pharmacist-in-charge.
Why this works. It acknowledges, explains, apologises for the experience without conceding clinical fault, states a concrete corrective action, and leaves a named contact. That structure resolves the complaint and protects the hospital's record at the same time.