Prescription Audit and Dispensing Errors in the Outpatient Pharmacy of Tertiary Care Multispecialty Teaching Hospital

Background: Although errors occurring during the process of dispensing may affect the goal of the treatment, they also can be the significant cause of morbidity and mortality. There are only few published evidences which focuses on the errors of dispensing that occurs in the pharmacy. This study focuses on identifying the dispensing errors, impact of brand substitution on cost and DDIs. Objective: To identify the dispensing errors, impact of brand substitution on cost and DDIs. Methodology: Prospective observational study conducted over a period of eight weeks in outpatient hospital pharmacy of tertiary care multispecialty teaching hospital, Tamil Nadu. Prescriptions and medication bills and dispensed medicines are collected from the hospital pharmacy to obtain data required for the study. Prescription containing only medical devices were excluded from the study. Results: Out of 1010 prescriptions, dispensing errors were present in 419 (41.48%) prescriptions which consist of 557 errors. The errors include dispensing multi-pills to make the required dose is 3.77%,tablet splitting is 0.8%, incorrect strength is 1.07%, omission error due to unavailability is 31.4%,dispensing drugs with brands other than prescribed brands is 63.7%. Prescriptions which had more than three drugs were analyzed for drug-drug interactions (n=389). DDIs were present in 156(40.1%) prescriptions which had a total of 281 interactions. Conclusion: The brand substitution and omission errors are the major causes of dispensing errors. Brand substitution is not always recommended as it may have some adverse effects because of salt and excipients variation. Pharmacists are in the position to identify and reduce DDIs by discussing with the physicians.

Study on Prescription Audit from a Rural Tertiary Care Hospital in North India

Evidence concerning prescription audits conducted in developing countries like India is scarce, especially from the rural parts of the country. Therefore, the present prescription audit was undertaken in a rural tertiary care hospital to investigate prescriptions for their completeness, in format of prescription, legibility of writing and it was assessed against the World Health Organization (WHO) recommendation of core indicators for prescription writing in order to investigate the rational usage of drugs. A total of 200 prescriptions were randomly selected, irrespective of clinical departments, patient characteristics and diagnosis over a period of six months. All the prescriptions were prospectively analyzed and conferred to an assessment of the quality of prescribing practice, general details, medical components, WHO core drug use indicators and legibility. Amongst the 200 prescriptions precisely monitored, we found that 100% prescriptions had general details of the patients such as name, age, gender, OPD/IPD registration number, hospital name & address and consulting unit/department. While evaluating the handwriting of the doctors, 83.5% (177/200) of the prescriptions had legible handwriting, wherein the degree of legibility showed 68.5% (137/200) prescriptions with easy legibility, 20% (40/200) difficult legibility while 11.5% (23/200) were illegible. Along with the different types of drugs obtained from the selected prescriptions, we found that antibiotics were prescribed in 51.5% (103/200) of the prescriptions. A prescription audit is a good tool to systemically review the day to day work, maintenance of records and assessment of accuracy of the diagnosis given by doctors and also the outcome of the treatment received.

Post-Prescription Audit Plus Beta-D-Glucan Assessment Decrease Echinocandin Use in People with Suspected Invasive Candidiasis

Background and Objectives: Overtreatment with antifungal drugs is often observed. Antifungal stewardship (AFS) focuses on optimizing the treatment for invasive fungal diseases. The objective of the present study was to evaluate the utility of a post-prescription audit plus beta-D-glucan (BDG) assessment on reducing echinocandin use in persons with suspected invasive candidiasis. Materials and Methods: This is a prospective, pre-post quasi-experimental study of people starting echinocandins for suspected invasive candidiasis. The intervention of the study included review of each echinocandin prescription and discontinuation of treatment if a very low probability of fungal disease or a negative BDG value were found. Pre-intervention data were compared with the intervention phase. The primary outcome of the study was the duration of echinocandin therapy. Secondary outcomes were length of hospital stay and mortality. Results: Ninety-two echinocandin prescriptions were reviewed, 49 (53.3%) in the pre-intervention phase and 43 (46.7%) in the intervention phase. Discontinuation of antifungal therapy was possible in 21 of the 43 patients in the intervention phase (48.8%). The duration of echinocandin therapy was 7.4 (SD 4.7) in the pre-intervention phase, 4.1 days (SD 2.9) in persons undergoing the intervention, and 8.6 (SD 7.3) in persons in whom the intervention was not feasible (p at ANOVA = 0.016). Length of stay and mortality did not differ between pre-intervention and intervention phases. Conclusions: An intervention based on pre-prescription restriction and post-prescription audit when combined with BDG measurement is effective in optimizing antifungal therapy by significantly reducing excessive treatment duration.

Enhancement and evaluation of a prescription audit system for direct oral anticoagulants using a check sheet

Background Renal function and use of concomitant medications should be carefully monitored in patients subjected to treatment with direct oral anticoagulants (DOACs); the dose should be individually designed for each patient. Owing to the complex therapeutic indications and dose reduction criteria, pharmacists exercise caution when determining the optimal dose for each patient. A DOAC check sheet has been developed that is automatically printed in the dispensing room at the same time as the prescription and can be used by pharmacists to dispense DOACs promptly and correctly. The purpose of this study was to evaluate the system for dispensing DOACs using a check sheet. Methods The study was conducted at Tohoku University Hospital in Japan; prescriptions containing DOACs dispensed by the hospital pharmacists were evaluated. The DOAC check sheet described indications, dosage regimens, dose reduction criteria, and contraindications for each drug and included the patient’s information. The check sheet was set to print automatically in the dispensing room at the same time as the prescription when an inpatient was prescribed DOACs. This check sheet was evaluated using a prescription survey and a questionnaire for pharmacists. Results The usefulness of this check sheet for the correct use of DOACs was evaluated. There were four inquiries out of 642 (0.6%) prescriptions from pharmacists to physicians regarding DOAC prescriptions, such as the dose introduced before DOAC check sheet utilization, and there were 21 out of 905 (2.3%) prescriptions when the DOAC check sheet was used it, showing a significant increase (p = 0.0089). After the introduction of this sheet, overdoses of DOACs were identified at the time of dispensing. Of the 52 pharmacists who responded to the questionnaire, 51 (98%) stated that the check sheet was useful. Conclusion The use of the DOAC check sheet is likely to render safety to DOAC drug therapy for individual patients.

PRESCRIPTION AUDIT IN OUTPATIENT DEPARTMENTS OF TERTIARY CARE HOSPITALS; FACTS AND RECOMMENDATIONS

Objective: To evaluate written prescriptions according to a checklist based on WHO guidelines (prescription audit). To compare prescriptions of senior and junior physicians and to provide data and recommendations. Study Design: Cross-sectional, analytic study. Place and Duration of Study: Pak Emirates Military Hospital, and Combined Military Hospital, Rawalpindi Pakistan, from March to Aug 2018. Methodology: A total of 205 prescriptions using convenient sampling technique were analyzed according to a checklist based on WHO guidelines for standard prescription writing. Data was analyzed using SPSS-22. Results: Out of total 205 prescriptions, 83 (40%) prescriptions belong to senior and 122 (60%) to junior physicians. Fifty (25%) prescriptions lacked patient name, 49 (24%) lacked age. Gender was mentioned in only 117 (57%) prescriptions. Date, diagnosis and dosage of drug were written in 170 (83%), 172 (84%) and 177 (86%) respectively while dosage form and route of administration were mentioned in 144 (70%) and 102 (50%) respectively. Generic name was written in only 75 (37%) prescriptions. Name and stamp of the doctor were available on 135 (66%) and 125 (61%) prescriptions respectively. A statistically significant association was observed between senior and junior physicians in terms of error in name of patient and dosage form (p=0.002& 0.005 respectively). Conclusions: Prescriptions were mainly deficient in the generic names of drugs. Route of administration was missing in half of the prescriptions. None of the parameters was totally accurate. Prescriptions from junior physicians had more errors.

Outpatient Fluoroquinolone Prescription Fills in the United States, 2014-2020: Assessing the Impact of Food and Drug Administration Safety Warnings

Background: The impact of United States (US) Food and Drug Administration (FDA) safety warnings on outpatient fluoroquinolone use is unclear. Methods: Annual changes in outpatient ciprofloxacin, levofloxacin and moxifloxacin prescription fills (IQVIA National Prescription Audit databases) were assessed using a regression model. Monthly fills during baseline (August 2014–April 2016), first (May 2016–June 2018), and second FDA warning periods (July 2018–February 2020) were compared by interrupted time series analysis. Results: From 2015 through 2019, total fluoroquinolone fills decreased from 35,616,786 (111.1/1000 persons) to 21,100,050 (64.3/1000 persons) annually (10.8% annually (P=0.001)). Ciprofloxacin, levofloxacin, and moxifloxacin fills decreased annually by 10.4% (P=0.001), 11.2% (P<0.001), and 17.7% (P=0.008), respectively. During the baseline period, there was no significant change in monthly fluoroquinolone fills. In May 2016 and during the first warning period, monthly fluoroquinolone fills decreased significantly (P-values<0.001); the trend of decreased fills was significantly greater than that of the baseline period (P=0.02). There was no change in fluoroquinolone fills in July 2018. Monthly fills decreased significantly throughout the second warning period (P<0.001), but the trend did not differ from that of the first warning period. Trends for ciprofloxacin, the most commonly prescribed fluoroquinolone, were similar to those for the class. Fills of prescriptions by infectious diseases specialists (P<0.005) and nurse practitioners (P=0.04) significantly increased during the study. Conclusions: US outpatient fluoroquinolone prescription fills significantly decreased from August 2014-February 2020, most strongly in association with May 2016 FDA warnings. FDA safety warnings are useful tools for leveraging outpatient antimicrobial stewardship.

ROLE OF CLINICAL PHARMACIST IN CLINICAL AUDIT AT DEPARTMENT OF GENERAL MEDICINE

Background of the study: Inaccuracy in writing and poor legibility of handwriting or incomplete writing of a prescription can lead to misinterpretation, thus leading to errors in dispensing and administration. Both individual and system related factors are responsible for prescribing errors. Recognition is the essential step in building safer systems and preventing errors. These errors can be detected by systematic analysis of prescriptions through a prescription audit. Hence, this project was proposed to improve the prescription practice by recommending the prescribing and therapeutic interventions in a selected setting of Anantapur. Research Methodology: The study was approved by the ethical committee of the hospital. Before starting the study, the researcher obtained formal permission from Government General Hospital, Anantapuramu. The data collection period was for 6 months. A prospective observational design was adopted for this study. The prescriptions were selected on the basis of inclusion criteria. Descriptive statistics like frequency and percentage were calculated to describe the data. Results and discussion: The overall observation made from this study was that clinical pharmacist could identify some drug related problems, provides clinical pharmacy services and contribute to better patient care being a part of the healthcare team. Conclusion: There is enormous scope for the clinical pharmacist to play an important role in health care in various aspects like monitoring ADRs, provision of drug information, identifying DRPs and patient counseling which will bring better patient outcome. Key words: Adverse drug reactions, Clinical audit, Clinical Pharmacist, prescription audit