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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 1  |  Issue : 1  |  Page : 13-18

Prescription audit study from a tertiary care private hospital in Kolkata, India


1 Department of Academics, Quality and Research, Peerless Hospitex Hospital and Research Center Ltd., Kolkata, West Bengal, India
2 Department of Clinical Research and Academics, Peerless Hospitex Hospital and Research Center Ltd., Kolkata, West Bengal, India
3 Department of Pharmacy Practice, Manipal College of Pharmacy, Manipal, Karnataka, India
4 Department of Medical Administration and Quality Assurance , Peerless Hospitex Hospital and Research Center Ltd., Kolkata, West Bengal, India
5 Department of Quality Assurance, Peerless Hospitex Hospital and Research Center Ltd., Kolkata, West Bengal, India

Date of Web Publication26-Jul-2019

Correspondence Address:
Dr. Subhrojyoti Bhowmick
Peerless Hospitex Hospital and Research Center Ltd., 360, Panchasayar, Kolkata - 700 094, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/QAIJ.QAIJ_5_19

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  Abstract 

Introduction: Prescription writing is an important aspect of safe medication practices. Prescriptions should adhere to best practices mentioned in the World Health Organization guidelines and the National Accreditation Board for Hospitals and Healthcare Providers guidelines. Aim: Evidence about prescription audit study conducted in developing countries like India is scarce, especially from the Eastern part of the country. Hence, the current prescription audit study was conducted in a tertiary care private hospital in Eastern India in the city of Kolkata. Materials and Methods: This study presents an assessment of the quality of prescribing practice in a tertiary care private hospital in Kolkata. Six thousand four hundred and six medicine cards (6406) of inpatients were prospectively analyzed for the duration of 6 months. Results: The audit revealed that only 69.24% of medicine cards had captured drug allergy, 99.53% had mentioned the route of administration, 99.85% had dose strength, 99.89% had mentioned the frequency of dose, and only 75.35% had mentioned the indication/diagnosis of patients. Surprisingly, 90.75% of medicine cards had an error-prone abbreviation which was an issue of major concern. Conclusions: The audit report was shared with the clinicians every month along with regular training of good prescribing practices, which improved the quality of prescribing practice. Regular prescription audit followed by dedicated clinical pharmacology team along with constant communication with clinicians can improve the quality of prescriptions in long run.

Keywords: Medicine cards, National Accreditation Board for Hospitals and Healthcare Providers guidelines, prescribing indicators, prescription audit, World Health Organization guidelines


How to cite this article:
Bhowmick S, Jana S, Parolia S, Das A, Saren P. Prescription audit study from a tertiary care private hospital in Kolkata, India. QAI J Healthc Qual Patient Saf 2019;1:13-8

How to cite this URL:
Bhowmick S, Jana S, Parolia S, Das A, Saren P. Prescription audit study from a tertiary care private hospital in Kolkata, India. QAI J Healthc Qual Patient Saf [serial online] 2019 [cited 2019 Aug 20];1:13-8. Available from: http://www.QAIJ.org/text.asp?2019/1/1/13/263596


  Introduction Top


Prescription writing is an art, but unlike other forms of art, this one must comply with good practice guidelines. Prescription audit is an active process that checks for improvement in quality of health care.[1],[2] An audit is defined as “the review and the evaluation of the health-care procedures and documentation to compare the quality of care which is provided, with the accepted standards.”[3],[4],[5] Prescription writing assessment is the most important technique to ensure rational use of drugs.[6],[7]


  Materials and Methods Top


This study was conducted in a tertiary care hospital in Kolkata, Eastern India. This prospective, cross-sectional study was conducted in various indoor patient departments of a 400-bed tertiary care hospital in Kolkata from a period of July 2017 to December 2017. Patients receiving medications during their treatment visits were documented.

Inclusion criteria

  1. The indoor patient prescriptions were reviewed
  2. Prescriptions were reviewed only after 48 h of the patient's admission to the hospital.


Exclusion criteria

  1. Patients admitted for day care were excluded from the study
  2. Newborn patients admitted in nursery area were excluded from the study.


Source of data

From the indoor patient department, medicine card files were collected, the data were stored and documented, and the data scrutiny procedures were adopted and reported to the quality department for further analysis. No patient interaction was considered, and only the patient medicine cards were referred after taking prior permission from the hospital authority. One skilled, qualified pharmacist collected the data from the patient bedside in various departments and documented it using computer software such as Microsoft 2007, (Microsoft Corporation, Redmond campus in Redmond, Washington) and Tata HMS with legitimate permit from the proper authority.

  1. Prescription audit was done based on some selected parameters
  2. The prescriptions of the indoor patients were checked thoroughly for the detection of compliance and noncompliance corresponding to the below-mentioned parameters:


Patient information

  1. Patient initials
  2. Patient's sex and age.


General information

  1. Patient IP number.


Prescribed drug information

  1. Drug allergy
  2. Route of administration
  3. Drug strength
  4. Frequency of dose
  5. Indication/diagnosis
  6. Error-prone abbreviation
  7. Date
  8. Signature
  9. Therapeutic duplication
  10. Drug written in capital letters.


Prescribing indicators

The following indicators were used to measure and analyze the prescription to review the quality of the prescription.

Drug allergy mentioned in medicine cards

This indicator helps in checking evidence of drug allergy/sensitivity in patients to a drug (s). Polypharmacy, which is the unnecessary prescribing of multiple drugs without proper indication, increases the pill burden and thus leads to increase in the chances of adverse drug reactions and drug–drug interactions along with decrease in the patient compliance.[5]

Routes of administration mentioned in medicine cards

This indicator helps in calculating the number of times the route of administration for a particular drug mentioned in the medicine card. A single drug can have multiple routes of administration depending on its dosage form. The onset of action of drugs depends greatly on the method of administration. This directly influences the drug's bioavailability in the patient's system, and thereby, the selection of a proper route of administration has a direct effect on the quality of therapy. This also helps in checking the rationality of the therapy because parenteral routes are comparatively more expensive than parenteral routes of administration for the same drug. Thus, rationality can be maintained by opting for the cheaper alternative of the dosage form for the same drug. This leads to improvement in the quality of health care that is provided in the institution.[8]

Dose mentioned in the medicine cards

This indicator helps in assessing the total number of times the dose for the particular drug mentioned in the medicine card. Mentioning the dose in the card improves the quality of therapy by clarifying the plan of therapy to the patient and by helping the pharmacist to dispense the drug of the mentioned dose. This indicator might also be used in calculating the total number of injections prescribed. Excess/indiscriminate use may lead to serious adverse events, hypersensitivity reactions, thrombophlebitis, etc., Furthermore, prescribing excess injections leads to increase in the financial burden on the patient, leading to irrationality in prescribing practices.

Indication/diagnosis mentioned in medicine cards

This indicator checks whether the proper indication/diagnosis for a particular patient has been mentioned in the medicine card or not. This helps in the easy identification of the patient according to his/her condition(s) by the physician/nurses/pharmacist/other health-care providers.

Error-prone abbreviations encountered in medicine cards

The use of abbreviations, symbols, and improper units of dose may save prescriber's time, but doing that sometimes might lead to some serious medicine-related errors in patients due to misinterpretation by the pharmacist during dispensing or when the patient takes the drug. There have been multiple reports of overdosing in patients, some of them even being lethal. There has been “μg” written instead of “Mcg” as per hospital protocol or policy.

Frequency mentioned in medicine cards

This indicator helps in calculating the total number of prescriptions containing the appropriate frequencies of the drug prescribed. This information is of vital importance for physicians/nurses in the intensive care unit/intensive treatment unit where parenteral routes including high-risk medications have to be administered at strict intervals. Thus, this indicator directly assesses the quality of health care in hospital settings.

Date mentioned in medicine cards

The date is a vital part of a prescription. It provides information about the last visiting date of a patient to the physician and assists in calculating the refilling date/schedule for drugs and the duration between two consecutive visits.

Prescriber's signature encountered in medicine cards

Signature is another vital element of a prescription. It acknowledges the prescriber's authority over the prescription. Signature also helps in validating the prescription as a proof that health care was provided by the patient.

Therapeutic duplication encountered

Therapeutic duplication is when a prescriber prescribes multiple drugs for the same category or class in a patient without producing any evidence of when one should be preferred over the other. Many a time, this leads to polypharmacy, thereby significantly increasing the chances of drug–drug interactions.

Drugs written in capital letters in medicine cards

Drugs must always be written in capital letters to prevent the wrong drug from being dispensed. Name of the drugs written by physicians with poor handwriting is the leading cause of error due to dispensing of wrong medicines. Thus, an effort must be made to encourage the use of capital letters while writing the names of drugs on the prescriptions to make it seem legible for clinicians/pharmacists. This can drastically improve the quality of health care in such facilities.

Data analysis

The data collected from different indoor patient departments were documented and analyzed using Microsoft Excel Version 2007. The following formulas were used to analyze the indicators collected from the data source.

  • Percentage of prescriptions in which drugs were written in capital letters = (Number of prescriptions in which drugs were written in capital letters/total number of prescriptions) ×100
  • Percentage of prescriptions in which drug allergies were mentioned = (Number of prescriptions in which drug allergies were mentioned/total number of prescriptions) ×100
  • Percentage of prescriptions in which routes of administration were mentioned = (Number of prescriptions in which routes of administration were mentioned/total number of prescriptions) × 100
  • Percentage of prescriptions in which drug strength was mentioned = (Number of prescriptions in which drug strength was mentioned/total number of prescriptions) × 100
  • Percentage of prescriptions in which indication was mentioned = (Number of prescriptions in which indication was mentioned/total number of prescription) × 100
  • Percentage of error-prone abbreviations encountered = (Number of prescriptions which had error-prone abbreviations/total number of prescription) × 100
  • Percentage of prescriptions which had date on them = (Number of prescriptions containing the date/total number of prescription) × 100
  • Because all the prescriptions are automatically generated on daily basis, all of them contain the date
  • Percentage of prescriptions containing the prescriber's signature = (Number of prescriptions containing the prescriber's signature/total number of prescription) × 100
  • Percentage of therapeutic duplication encountered = (Number of prescriptions containing therapeutic duplication/total number of prescription) × 100
  • Percentage of prescriptions which had frequency of dose on them = (Number of prescriptions containing the frequency of dose/total number of prescription) × 100.



  Results Top


There were a total of 10 parameters to be assessed for the prescription audit. A total of 6406 sample of prescriptions were audited.

[Table 1] and [Figure 1] show all medicine departments such as cardiology department, gastroenterology department, general medicine/respiratory medicine department, nephrology department, and pediatric department.
Table 1: Medicine department analysis

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Figure 1: Medicine department

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[Table 2] and [Figure 2] show all surgical departments such as cardiothoracic surgery, gastroenterology surgery, general surgery, gynecology and obstetrics, orthopedics, ENT, and miscellaneous (urology, neurology, hematology, dental, oncology, and diabetology).
Table 2: Surgery department

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Figure 2: Surgery departments

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The data produced from the study of various departments showed that drug allergy in the 1st month was reported to be 62.95%, whereas in the 6th month, it was 70.44%; route of administration in the 1st month was 100%, and in the 6th month, it was found to be 99.55%; dose documentation in the 1st month was 100%, whereas in the 6th month, it was 99.50%; frequency documentation in the 1st month was 100%, and in the 6th month, it was 98.6%; diagnosis documentation in the 1st month was 75.53%, whereas in the 6th month, it was 72.4%; avoidance of error-prone abbreviation in the 1st month was 88.42%, and in the 6th month, it was 91.82%; prescribing date documentation in the 1st month was 96.55%, whereas in the 6th month it was 97.85%; prescriber signature in the 1st month was 99.91%, whereas in the 6th month, it was 99.81%; compliance rate on therapeutic duplication in the 1st month was 100%, and in the 6th month also, it was found to be 100%; and drug written in capital letters in the 1st month was 93.73%, and in the 6th month, it was 93.78%.


  Discussion Top


This audit of the indoor patient prescriptions in various departments in the hospital was an eye-opening experience. The main objective was to assess the rationality of the prescription by the physicians in a hospital and to check whether they met the appropriate standards of good prescribing practices. This study showed that 9.25% (n = 1422) of the total medicine cards audited in the hospital had some form of error-prone abbreviations. It was also revealed that 6.2% (n = 324) of the prescriptions had names of drugs written in small letters. In general, poor handwriting is the leading cause of medicine-related errors. However, the most interesting find out of this study was that only 69.24% (n = 4403) of the total prescriptions (n = 6406) reviewed contained proper drug allergy mentioned on them. This is a common element missed during history taking by the doctors, and previous studies have documented the same finding.[3] There have been limited studies conducted on prescription audits in India, but all of them used the World Health Organization (WHO) prescribing indicators to assess the quality of prescribing. This study is one of the very few studies that utilize the National Accreditation Board for Hospitals and Healthcare Providers (NABH) prescribing indicators in the Indian subcontinent.[3] In a similar study, the name of all the physicians and hospital address were printed on the prescriptions, but none mentioned the doctor's registration number and 17% prescriptions did not have the physician's initials.[9] In this study, we shared the results of the audit every month with the clinicians and followed it up with a regular training on good prescribing practices as per the NABH guidelines. Hence, at the end of the study, the prescriber's signature was present on 99.83% of all prescriptions. Similar type of studies has shown that irrational and unchecked prescription practices, otherwise known as polypharmacy, lead to noncompliance and unnecessary cost burden on the patients.[2],[7],[9],[10],[11] Conducting prescription audits frequently in hospitals and community pharmacies helps in the better understanding of the prescribing behavior of the physicians and reduces the risk of medication error by improving the quality of health care in these sectors.[7]

Strengths of this study include 6406 prescriptions being audited which is the largest sample size done in the recent past. It is also the first study from the Eastern India where compliance to NABH's prescribing indicators has been studied. Other strengths of this study include avoiding selection bias to the maximum extent by collecting almost all the prescriptions in various departments. Some of the drawbacks of the study include not studying other complimentary indicators such as WHO drug use indicators, unicentric study nature, and it was time-bound as the data collection spanned for a period of 6 months only.

Nevertheless, this study highlights that regular prescription audit followed by constant communication and training of the clinician is the most effective way to improve prescription practice within the hospital.


  Conclusions Top


This study calls for a need to implement the NABH standards for prescribing techniques in the hospitals. Some hospitals already have these standards setup, but their incorporation by the practitioners is yet to take place. Unless this occurs, the quality of patient care will not improve.

There is a dire need of regular prescription audit to be conducted by dedicated clinical pharmacology team along with regular communication with the prescribers.

Acknowledgment

We would like to thank the nursing staff and staff from the Department of Quality and Doctors of Peerless Hospitex Hospital and Research Center Ltd., Kolkata, West Bengal, India, for their support during the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sarkar PK. A rational drug policy. Indian J Med Ethics 2004;1:11-2.  Back to cited text no. 1
    
2.
Panayappan L, Jose JM, Joseph JG, Jayapal K, Saju S, KrishnaKumar K. Prescription audit and prescribing indicators: A review. J Bio Innov 2017;6:542-7.  Back to cited text no. 2
    
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Solanki ND, Shah C. Prescription audit in outpatient department of multispecialty hospital in Western India: An observational study. Int J Clin Trials 2015;2:14-9.  Back to cited text no. 3
    
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Patterson HR. The problems of audit and research. J R Coll Gen Pract 1986;36:196.  Back to cited text no. 4
    
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Srishyla M, Mahesh K, Nagarani M, Mary C, Andrade C, Venkataraman B. Prescription audit in an Indian hospital setting using the DDD (defined daily dose) concept. Indian J Pharmacol 1994;26:238.  Back to cited text no. 5
    
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Curtis P, Coll JR. Medical audit in general practice. Gen Pract 1974;24:607-11.  Back to cited text no. 6
    
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Jyoti N, Kaur S. To analyze the impact of serial prescription audits with active feedback on quality of prescription behaviour. J Clin Diagn Res 2013;7:680-3.  Back to cited text no. 7
    
8.
Potharaju HR, Kabra SG. Prescription audit of outpatient attendees of secondary level government hospitals in Maharashtra. Indian J Pharmacol 2011;43:150-6.  Back to cited text no. 8
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9.
Janmano P, Chaichanawirote U, Kongkaew C. Analysis of medication consultation networks and reporting medication errors: A mixed methods study. BMC Health Serv Res 2018;18:221.  Back to cited text no. 9
    
10.
Mishra S, Sharma P. Prescription audit and drug utilization pattern in a tertiary care teaching hospital in Bhopal. Int J Basic Clin Pharmacol 2016;5:1845-9.  Back to cited text no. 10
    
11.
Aravamuthan A, Arputhavanan M, Subramaniam K, Udaya Chander JS. Assessment of current prescribing practices using World Health Organization core drug use and complementary indicators in selected rural community pharmacies in Southern India. J Pharm Policy Pract 2017;10:1.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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