ABSTRACT
Background:Correct prescription writing habits could have a great influence on the fate of drug therapy as well as the health of patients. The aim of the study was to determine the prescription writing errors from the outpatient department of pediatrics in a teaching Hospital.
Subject and methods: A nine month hospital based prospective study was carried out after obtaining ethical clearance certificate. A total of 220 prescriptions were randomly collected and analyzed.
Results: Among them 279 errors of omission related to prescriber and 236 errors of omission related to drugs with an average of 1.26 and1.07 error per prescription were reported respectively. Among errors of omission related to the prescriber, prescribers name was not written in 215 (97.72%) followed by weight18 (8.18%) and illegible prescriptions were 18(8.18%). Regarding errors omission related to the drugs, duration/no. of doses was not mentioned in124 (53.36%) followed by quantity to supply76 (34.54%), strength 26(11.80%) and frequency 10 (4.54%) of prescriptions respectively. A total of 79 errors of commission were reported with an average of 0.28 errors per prescription. Among them errors regarding wrong dosage form were 47(21.36%) followed by wrong strength13 (5.90%), wrong drug name11 (5%) and drug-drug interactions 8(3.63%) of prescriptions respectively.
Conclusion: The study results indicate that errors in prescription writing were significant at the study site, which highlights the need of conducting the educational programs to improve the prescription writing skills of the prescribers.

Keywords: Prescription, Errors, Omission, Commission, NCCMERP.

INTRODUCTION

Drugs play an important role in protecting, maintaining and restoring health. Prescription writing is a science and an art, as it conveys the message from the prescriber to the patient (Ather et al., 2013, Kishore, 2006). Prescription is a written order from physician to pharmacist which contains name of drug, its dose and its method of dispensing and advice over consuming it. Hence correct prescription writing habits could have a great influence on the fate of drug therapy as well as the health of patients (Ather et al., 2013; Mortazavi and Hajebi, 2003).
The interaction between a doctor and patient usually culminates in the writing of a prescription order. The energies, skills and time put into making a diagnosis and formulating appropriate therapy could be wasted if adequate attention was not given to the details that ought to be included in a well-written prescription. A prescription order should clearly communicate with a pharmacist/dispenser what therapy a particular patient is to get: how much of a specific medicine should be taken, how often and for how long. It should also clearly identify the prescriber, be signed in ink, and be dated (British National Formulary, 2006). Children have a three-fold greater risk of experiencing a medication error than adults and are more likely to be harmed (Kaushal et al., 2001).
Hence the components of a prescription should be clearly written, free from writing errors, non-official abbreviations, and fulfill the legal requirements of a prescription. Prescription witting errors may be classified into two main types: errors of omission (incomplete prescription) and errors of commission (incorrect information). Since these errors are the commonest form of avoidable medication errors, it is the most important target for improvement (Ansari and Neupane, 2009). An error is ‘something incorrectly done through ignorance or inadvertence; a mistake, e.g. in calculation, judgment, speech, writing, action, etc.’ or ‘a failure to complete a planned action as intended, or the use of an incorrect plan of action’ to achieve a given aim (Aronson, 2009).
Prescriptions containing errors communicate incompletely or inadequately to the pharmacist and may have various detrimental consequences. Some errors will require the pharmacist simply to use additional professional judgment in the interpretation and execution of the prescription. Omission errors may cause the pharmacist, physician, and patient to waste time while the pharmacist calls the physician to complete the communication process. Unfulfilled legal requirements prevent the prescriptions from being executed or may transfer liability to the pharmacist if the prescription is dispense (Shaughnessy and Nickel, 1989). Whereas the errors of commission should promptly be detected and corrected, otherwise patient’s health could be threatened or at least the proposed treatment program would be put in danger (Mortazavi and Hajebi, 2003). The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) reported that 15% of the medication errors occurred because of illegible handwriting, problems with leading and trailing zeroes, misinterpreted abbreviations, and incomplete medication orders (Meyer, 2000).
The above fact indicates that, the prescription writing errors leads to the medication errors. This in turn leads to the failure of therapeutic goals. Most of the prescription writing errors are avoidable errors. The pharmacist can play an important role in this regard. Hence the present study was conducted to evaluate the prescription writing errors; by way of this the need of educating the prescribers in prescription writing will be determined. This will help to reduce the medication errors due to prescription writing.

SUBJECT AND METHODS

A nine month prospective study was carried out with the prior permission from the Department of Pediatric, Basaveshwar Teaching and General Hospital Gulbarga, KA, India and after obtaining Institutional Ethical Clearance, to determine the prescription writing errors at teaching and general hospital. A total of 220 prescriptions were randomly collected from out- patients visiting the department of medicine and willing to participate in the study. The prescriptions of In-patients from Department of Medicine were excluded from the study site. The prescription writing errors such as errors of omission related to prescriber (Patients name, Age, O/P Number, Date, Prescribers name, Prescribers signature, Clinic/Department, Weight, Diagnosis and illegible prescriptions); errors of omission related to drugs (Route of administration, Dose, Frequency, Strength, Dosage form, Duration/number of doses, Quantity to supply) and Errors of commission (Wrong strength, Wrong dosage form, Drug-drug interactions, Wrong drug name) were documented in a suitably designed documentation form.
Data analysis
From the data collected the percentage (%) of various errors related to the errors of omission and errors of commission were calculated and analyzed.

RESULTS

Prescription writing errors
Out of 220 prescriptions a total of 279 errors of omission related to prescriber were reported with an average of 1.26 errors per prescription and 236 errors of omission related to drugs were reported with an average of 1.07 errors per prescription and also a total of 79 errors of commission were reported with an average of 0.35 error per prescription (Table 1).

Table1. Prescription writing errors. Click here to view full image

Errors of omission
Among 515 errors of omission, 279 errors of omission related to prescriber (1.26 errors per prescription) were reported (Table 1) due to failure to mention prescribers name 215 (97.72%) fallowed by weight 18 (8.18%) , illegible prescriptions were18 (8.18%), signature of prescriber 16 (7.27%), diagnosis 12 (5.45%), (Table 2) respectively, and 236 errors of omission related to drugs (1.07errors per prescription) were reported due to failure to mention duration/no of doses 124 (53.36%), quantity to supply 76 (34.54%), strength 26 (11.8%), and frequency 10 (5.4%) respectively (Table 3).

Table2. Errors of omission related to the prescriber. Click here to view full image

Table3. Errors of omission related to the drugs. Click here to view full image

Errors of commission
Among 220 prescriptions, 79 errors of commission were found. Among them errors regarding wrong dosage form were 47 (21.36%) followed by wrong strength 13 (5.90%), wrong drug name 11 (5%) and drug-drug interactions 8 (3.63%) prescriptions.

Table4. Errors of commission. Click here to view full image

DISCUSSION

The present study demonstrates a wide range of different types of errors (1.26 errors/prescriptions) associated with prescriptions writing about 97.72% of prescription. Weights of the patients were not mentioned in only 8.18% of prescriptions. Whereas age of the patients were mentioned in all prescription this showed that better knowledge about importance of weight and age in pediatric patients. Prescribers name and signature were not written in 97.72% and 7.27% of prescriptions. Duration/no. of doses was not mentioned in 53.36% followed by, strength 11.80% and frequency 4.54% (Table 2). Not a single error of omission found related to route of administration, dose and dosage form. Among 220 prescriptions, 79 errors of commission were found. Among them errors regarding wrong dosage form were 47 (21.36%) followed by wrong strength 13 (5.90%), wrong drug name 11 (5%) and drug-drug interactions 8 (3.63%) prescriptions. Whereas study conducted by Abdella and Wabe (2012) reported that prescribers name and signature not written in 83.6%, and 23.7% of prescriptions. Duration of treatment and strength were not written in 37.8% of prescriptions followed by frequency 23.67%, where as dose and route of administration were not written in 61.2% and 32.6%. Similar study conducted by Mugoyela et al. (2008) reported that, all prescriptions had at least one or more errors which involved omission of either the patients age (2.9%), name (1.6%), weight (93.8%), route of administration (94%), dose (5.4%), frequency (3.2%), dosage form (24.8%) and duration of treatment (14.1%). Errors of commission accounted for 3.1% of all prescribed medicines.
A study conducted by Kuan et al. (2002) reported 397 errors of omission related to prescriber and were due to failure to mention age (32.7%) followed by date (17.1%), clinic or department (16.4%), registration number (0.5%), prescriber’s name (1.8%) , prescriber’s signature (0.3%) and illegible hand writing (7.1%) and 862 errors of omission were due to failure to mention route of administration (80%), strength (56.3%), dosage form (36.4%), duration or number of doses (8.8%), dose (8.7%), quantity to supply (5.8%), frequency (5.3%) and drug name (0.2%) respectively. The present study reveals that the prescription writing errors at the study site were nearly similar (97.72%) when compare to study conducted by Kuan et al. (2002) (96.7%) respectively. In that study the major errors of omission were due to failure to mention prescribers name (97.72%) whereas study conducted by Ansari and Neupane (2009) showed nearly similar result (85.4%).
Accurately dispensing a pediatric prescription requires additional information not commonly found on a prescription for an adult, most notably the weight of the patient, which is especially important because it is often used to calculate the appropriate dose of a medication (e.g., mg/kg, mcg/kg, and mg/m2) (Levine et al., 2001). A prescribed medication dose can differ significantly from the appropriate dose as a result of missing or inaccurate patient weights. Pediatric/neonatal patients are at greater risk for adverse drug events because they may be more vulnerable to the effects of an error and their weight may change frequently over a short period of time. Patient information such as weight, age helps pediatric practitioners to select appropriate medications, doses, and routes of administration (Medication Errors, 2009). In the prescription failure to mention strength and dosage forms may pose some problems as many drugs are available in various strengths and dosage forms. The legibility of the prescription is subjective and it depends on the assessor’s familiarity with the handwriting of the prescriber. However, it should be emphasized that the prescription could be easily read by anyone involved in the dispensing, since the prescriptions could be filled by any pharmacy outside the hospital (Bhosale et al., 2013; Kuan et al., 2002). The errors of commission represent greater threat to the patient’s health than the errors of omission; hence they should be identified and corrected. The commission error such as wrong dosage form and wrong strength may lead to serious consequences as the same drug is available in various dosage forms and also in various strengths (Bhosale et al., 2013). For example amoxicillin is available in various dosage forms like dispersible tablets, capsules, dry syrup etc and in various strengths like 125 mg, 250 mg and 500 mg etc. This may lead to therapeutic failure due to over use or under use of the prescribed drugs. The drug-drug interactions may lead to serious complications and hence they should be systematically analyzed and properly managed. The majority of the prescription errors reported in the study were commonest forms of avoidable medication errors and it should be important target for the improvement.

CONCLUSION

The study results indicated that the prescription writing errors are significant at study site which highlights the need of conducting the educational programs to improve the prescription writing skills of the prescribers. This will help to reduce the medication errors due to prescription writing errors.

CONFLICT OF INTEREST
None declared.

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