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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 48-52

A study to assess the degree of adherence of prescription to WHO and MCI guidelines at a tertiary health care teaching hospital in North India


1 Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Hospital Administration, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Hospital Administration, Super Specialty Cancer Institute and Hospital, Hemwati Nandan Bahuguna Medical University, Dehradun, Uttarakhand, India

Date of Submission18-May-2019
Date of Decision15-Jul-2019
Date of Acceptance19-Sep-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Rajesh Harsvardhan
Department of Hospital Administration, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_12_19

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  Abstract 


Background: Prescription errors are one of the most common preventable medication errors. The occurrence of medication errors can compromise the patient confidence in the healthcare system and also increase healthcare costs. The aim of this study was to randomly audit medical prescriptions and associated factors at the outpatient department of a tertiary care teaching institute in Lucknow.
Methodology: A total of 420 prescriptions were randomly selected and reviewed. Data on the prescribed drugs were collected from prescription papers using a structured format and analysed using SPSS software. Data on patient demographics, indication for each medication, dosage, dosage form, regimen and concurrent medications were collected. Data on duration of medication were not evaluated.
Results: Out of 420 prescriptions included for review, date of prescription was documented in only 59% of cases. Signature of doctor was present in 94.2% prescriptions although the name of the prescriber was mentioned in only 27% prescriptions. The average number of drugs per prescription was 3.89%. Errors related to dosing were documented in 44% cases. Injectable drugs were prescribed in 26.6% prescriptions, whereas antibiotics were written in 13.8%. The percentage of drugs prescribed by generic name was only 7.61%. The understanding of patients regarding prescription of medication given to them, especially with regards to legibility of dose and timing was 55.7%.
Conclusion: The results of our study prove that prescribing errors are a major cause of preventable iatrogenic injury to patients. They may be rectified by educational intervention as well as standardised prescription charts.

Keywords: Audit, pharmacy, prescription


How to cite this article:
Mishra R, Harsvardhan R, Rai R, Chandra H. A study to assess the degree of adherence of prescription to WHO and MCI guidelines at a tertiary health care teaching hospital in North India. J Patient Saf Infect Control 2019;7:48-52

How to cite this URL:
Mishra R, Harsvardhan R, Rai R, Chandra H. A study to assess the degree of adherence of prescription to WHO and MCI guidelines at a tertiary health care teaching hospital in North India. J Patient Saf Infect Control [serial online] 2019 [cited 2020 Sep 25];7:48-52. Available from: http://www.jpsiconline.com/text.asp?2019/7/2/48/273730




  Introduction Top


Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. Almost everyone in the world has taken medication at one time or another in their life. Most of the time, the medications are favourable or at least they do no harm, but on occasion, they do harm the person taking them.[1] Sometimes, these harms are due to errors occurred during medication use process which can be prevented. In hospitals, errors occur in every step of the medication use process starting from procuring the drug to prescribing, transcribing, dispensing, administering and monitoring its effect.[2] Annually, 7000 mortalities have been reported due to medication errors.[3] It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths. Medication factors (e.g. similar-sounding names and low therapeutic index), patient factors (e.g., poor renal or hepatic function, impaired cognition and polypharmacy) and healthcare professional factors (e.g., use of abbreviations in prescriptions and other communications and cognitive biases) can precipitate medication errors.[4] In India, the medication errors and medication-related problems are mainly due to irrational use of medications.[5],[6]

Good prescribing practice is an essential part of the rational drug use.[7],[8] A prescription audit is a useful method to assess doctors' contribution in medication errors. Prescribing physicians as well as those who involved in the execution of the prescription hold a legal responsibility for prescription. A good quality prescription is an extremely important factor for minimising error in dispensing of medication and physicians should adhere to the guidelines for prescription writing for the benefit of the patient.[9]

Providing the right medicine to the right people at the right time is a central priority of healthcare. The way to ensure this is through the effective implementation of the World Health Organization's (WHO) recommendation on rational drug policies. In India, drugs worth 7000 crores ($2000 million) are consumed every year. It is acknowledged that substantial part of these drugs is either irrationally prescribed or available in irrational combinations. In the light of these findings, standard policy on the use of drugs must be set, and this can be done only after the current prescription practices have been audited.

Prescription errors are an important form of medication errors. In India, there are a few published studies pertaining to medication errors and prescription errors. Most of the published studies have addressed the issue of medication errors in indoor admitted patients. This study was planned to initiate the process of identification and subsequent minimisation of medication errors. As an initial step, this observational study was planned to look only for errors in prescription writing for outpatient department (OPD) patients. The study was carried out to identify the medication errors and adherence to mild cognitive impairment (MCI) and WHO prescription writing guidelines in a tertiary care hospital to create an awareness regarding the irrational use of medications by providing the feedback to the healthcare professionals.


  Methodology Top


A cross-sectional study was conducted for the duration of 1 month from 1 March 2018 to 31 March 2018 in the OPD Pharmacy of Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow. A total of 420 prescriptions of different department were randomly studied out of all prescriptions received in 1 month. The study of outpatient prescriptions was conducted in the busiest hours, catering to clinicians from multiple specialities in SGPGIMS, Lucknow. Prescriptions were collected with consent from the patients or their attendants as digital images and pooled up and analysed in the Excel sheet. The average number of drugs per encounter, percentage of drugs by generic name, percentage of encounters with antibiotics, percentage of encounters with injections and percentage of drugs adequately labelled, according to the WHO criteria were studied. Percentage of patients with correct understanding of prescription, especially with regards to legibility of dosage and timing was analysed by interviewing patients or their attendants.

Vaccine and local anaesthetics were not regarded as injections. Anti-diarrhoeal drugs with norfloxacin, ciprofloxacin and ofloxacin were considered as antibiotics. Combination drug was counted as one. All Allopathic practitioners' prescriptions were included and prescriptions with only syringes, gloves and other surgical items without any drugs in them were excluded from the study.

The prescription copies obtained were analysed as per the WHO selected drug use indicators. A checklist was prepared, and each prescription was analysed on various parameters as per the checklist given below:

  1. Patient details: Name, age and date of prescription
  2. Clinician details: Letterhead used, name, qualification, address and signature
  3. Drug details: Number of drugs, number of generics, number of antibiotics, number of injections, clarity of dosage, clarity of instructions, frequency of administration and duration of treatment
  4. Other information: legibility of prescription and mention of diagnosis.



  Results Top


The total number of prescriptions collected were 447 and 27 were excluded under exclusion criteria i.e prescription containing consumables, vaccines etc was not considered in the study. A total of 420 prescriptions were analysed from the OPD Pharmacy of tertiary care teaching hospital. Data were analysed on SPSS Inc. ver 17.0 as Yes = 1 and No = 0. The observations are shown in the following tables and figures.

Drug prescribing indicators

The following selected drug use indicators were calculated based on the observations noted [Table 1].
Table 1: The selected drug use indicators

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The average number of drugs per prescription in tertiary care teaching institute is 3.89. Percentage of drugs prescribed by generic name was 7.61%, percentage of prescriptions with antibiotics prescribed was 13.80% and percentage of prescriptions with an injection prescribed was 26.66% [Table 2].
Table 2: Layout, legibility, clarity and adequacy of labelling of prescriptions

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Layout, legibility, clarity and adequacy of labelling of prescriptions

The date of prescription was missing from nearly 41% of the prescriptions. Letter head was used in 97.1% of prescriptions. Doctor's name was mentioned only in 27.6% of prescriptions. None of the prescriptions stated the qualification of the doctor and only 10.4% stated the complete address. It was found that almost 94.2% of the prescriptions had doctors' signature. Majority of the prescriptions (81.9%) have patient's name, but only 41.9% of prescriptions had patient's age. Nearly 60% of the prescriptions were legible with 66.6% clarity of dosage and 35.3% of the prescriptions were lacking in diagnosis. Nearly, 94.3% of the prescriptions frequency of dosage and duration of treatment was stated.

Polypharmacy

The number of prescriptions with single drug and two drugs were nearly same as 14.2%. The prescriptions with three drugs were 20%, and the rest of the prescription had more than three drugs which ranged from 4 to 14 drugs.

Understanding of patients/attendants with regards to legibility of dosage and timing of medication prescribed

The patients and their attendants who came to pharmacy outlets were interviewed regarding their understanding of prescription with regards to legibility about dosage and timing of drugs. It was found that knowledge level was 55.7% [Table 3].
Table 3: Understanding of prescription with regards to legibility of dosage and timing (patient's/attendants interview)

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  Discussion Top


This cross-sectional study has been done as per the WHO published book – how to investigate the drug use in Health facilities, 1993,[10] and model prescription format of prescription recommended by MCI.[11] The drug prescribing pattern needs to be evaluated from time to time. The study revealed that average number of drugs per prescription was 3.89.

The average number of drugs per prescription is an important index to review, to plan and an educational intervention in prescribing practices. It was found that the number of drugs per prescription was higher than the WHO recommended values (1.6–1.8). Similar results were found in the studies done by Lamichhane et al. in a teaching hospital in Western Nepal in 2006, in which the average number of drugs per prescription was 1.99.[12] The study done in Northern India by Dimri et al. 2009 showed that the average number of drugs per prescription was 2.31.[13] According to the study by Mirza et al., 2009, done in Gujarat, the average number of drugs per prescription was 3.72.[14]

The percentages of drugs prescribed by generic name were 7.61%. The present study showed that the percentages of drugs prescribed by generic name were lower than the WHO recommended values. Dimri et al., 2009, showed the average number of drugs per prescription as 7.80. A study conducted by Maini et al. 2002 showed the average number of drugs per prescription as 6.90.[15] In spite of the fact that the Medical Council of India has recommended to prescribe only generic medication,[16] clinicians preferred to prescribe trade name with which they were familiar.

The percentage of prescriptions with an antibiotic and injection prescribed was found to be 13.80% and 26.66%, respectively. The values of antibiotic prescribed in the present study are well within the WHO recommended values (22.0%–26.8%), and the value of injections prescribed was beyond the prescribed WHO values (13.4%–24.1%).

The present study has highlighted the presence of severe deficiencies in the layout of a significant proportion of prescriptions. Around 59% of the prescriptions were lacking in the mentioning of date of prescription which is important from the medicolegal aspect. Since a number of prescriptions were not dated, there is a potential of the same prescription being reused for an indefinite period of time. The usage of letterhead was 97.1%. Several prescriptions lack even the basic information such as the identity, qualification and address of the practitioner. A considerable portion of prescriptions was lacking in the signature of prescribing doctor. Although patient's full name was mentioned in almost 81.9%, the age of the patient was mentioned in only 41.9%. Legibility of the prescriptions was 60% [Figure 1]. Clarity of the dosage was around 66.6%, but clarity of instructions was inadequate with only 34.2%. About half of the prescriptions did not mention the diagnosis. Diagnosis is important for the pharmacist to know the consistency of diagnosis and drugs, audit prescription and to know potential drug interactions and contraindications. About one-fifth of prescriptions were lacking in frequency of dosages and duration of treatment, which may result in lack of compliance to treatment and development of resistance to drugs [Figure 2].
Figure 1: Compliance for attributes of prescription

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Figure 2: Sample prescription

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Polypharmacy was observed in around 85% of prescriptions having more than one drug, with a significant proportion of patients receiving three or more drugs. Maximum number of drugs prescribed in a prescription was three. Since many preparations were multidrug combinations, the actual number of specific pharmaceutical entries prescribed was likely to be even higher. SGPGIMS is a tertiary care teaching hospital, and the patient comes here with complex diseases which require consultation from more than one specialty and that leads to the scenario of polypharmacy [Figure 3].
Figure 3: Understanding of prescription with regards to legibility of dosage and timing (patient's/attendants interview)

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It was found that percentage of patients with correct knowledge of dosage was 55.7. A study conducted by Hazra et al. in 2000 shows similar finding in which patients having knowledge of correct dosage was found to be 64.50.[17][Figure 3].


  Conclusion Top


The present study has highlighted the presence of significant inadequacies in prescriptions such as presence of date, doctor's name, qualification and complete address and mentioning of diagnosis There is a need to standardise the format of prescriptions in India, so that all essential information is included in the study. Interventions aimed at improving knowledge and training, and reducing complexity, and the introduction of strict feedback control and monitoring systems are highly advisable. However, large-scale information on the beneficial effects of interventions aimed at reducing harm from prescribing faults, and prescription errors are not yet available and are needed. Along with introduction of prescription audit, there is a greater need for public and patient education in the appropriate use of drugs, particularly antibiotics for achieving the goal of rational use of medicines; the limitation of the study is that use of over-the-counter medicines, and self-medication was not evaluated which accounts for a significant fraction of the drug use in India. In spite of the limitations, the present study could serve as a framework upon which further studies in prescription audit can be launched to investigate the scope for educational intervention and improvement in prescribing patterns.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Goulding PM. Prevention of Medical Errors; 2016. Available from: https://www.nursece.com/pdfs/2011_prevention_of_medical_errors.pdf. [Last accessed on 2016 Feb 01].  Back to cited text no. 1
    
2.
Aspeden P, Wolcot JA, Palugod RL, Bastein T. Preventing Medication Errors. Institute of Medicine 2016. Brief Report; in July, 2006. Available from: https://iom.nationalacademies.org. [Last accessed on 2016 Feb 01].  Back to cited text no. 2
    
3.
Hinojosa-Amaya JM, Rodríguez-García FG, Yeverino-Castro SG, Sánchez-Cárdenas M, Villarreal-Alarcón MÁ, Galarza-Delgado DÁ. Medication errors: Electronic vs. paper-based prescribing. Experience at a tertiary care university hospital. J Eval Clin Pract 2016;22:751-4.  Back to cited text no. 3
    
4.
Wittich CM, Burkle CM, Lanier WL. Medication errors: An overview for clinicians. Mayo Clin Proc 2014;89:1116-25.  Back to cited text no. 4
    
5.
Rajanandh MG, Varghese R, Ramasamy C. Assessment of drug information services in a South Indian tertiary care hospital in Kanchipuram district. Int J Pharm Pharm Sci 2011;3:273e-6.  Back to cited text no. 5
    
6.
Krishna J, Singh AK, Goel S, Singh Abhishek, Gupta Aakansha, Paneshar Sanjeet et al. A preliminary study on profile and pattern of medication errors from a tertiary care teaching hospital. IAIM 2015;2: e938.  Back to cited text no. 6
    
7.
Krishnaswamy K, Kumar BD, Radhaiah G. A drug survey – Precepts and practices. Eur J Clin Pharmacol 1985;29:363-70.  Back to cited text no. 7
    
8.
Pradhan SC, Shewade DG, Shashindran CH. Drug utilization studies. Natl Med J India 1998;1:185-9.  Back to cited text no. 8
    
9.
Meyer TA. Improving the quality of the order-writing process for inpatient orders and outpatient prescriptions. Am J Health Syst Pharm 2000;57 Suppl 4:S18-22.  Back to cited text no. 9
    
10.
Essential Medicines and Health Products Information Portal: A WHO Resource. Available from: https://apps.who.int/medicinedocs/en/d/Js2289e/8.2.html. [Last accessed on 2017 May 15, 08:00PM].  Back to cited text no. 10
    
11.
Available from: http://www.delhimedicalcouncil.org/pdf/modalprescription.pdf. [Last accessed on 2017 Jul15].  Back to cited text no. 11
    
12.
Lamichhane DC, Giri BR, Pathak OK, Panta OB, Shankar PR. Morbidity profile and prescribing patterns among outpatients in a teaching hospital in Western Nepal. Mcgill J Med 2006;9:126-33.  Back to cited text no. 12
    
13.
Dimri S, Tiwari P, Basu S, Parmar VR. Drug use pattern in children at a teaching hospital. Indian Pediatr 2009;46:165-7.  Back to cited text no. 13
    
14.
Mirza NY, Sagun D, Barna G. Prescribing pattern in a pediatric out-patient department in Gujarat A journal of the Bangladesh Pharmacological Society (BDPS). Bangladesh J Pharmacol 2009;4:39-42.  Back to cited text no. 14
    
15.
Maini R, Verma KK, Biswas NR, Agrawal SS. Drug utilization study in dermatology in a tertiary hospital in Delhi. Indian J Physiol Pharmacol 2002;46:107-10.  Back to cited text no. 15
    
16.
Indian Medical Council. (Professional Conduct, Etiquette and Ethics) Regulations, 2002. Part III, Section 4. Gazette of India; 2002.  Back to cited text no. 16
    
17.
Hazra A, Tripathi SK, Alam MS. Prescribing and dispensing activities at the health facilities of a non-governmental organization. Natl Med J India 2000;13:177-82.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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