Manipal College of Pharmaceutical Sciences, Manipal University. Manipal 576104
1.Why prescriptions need to be scrutinized?
The prescriptions are usually hand-written by doctors or physician-assistant under the direction of a doctor. When a doctor himself writes a prescription he needs to fill all the sections of the prescription and authenticate by putting his signature with date and time. Alternatively, the physician-assistant fills the prescription and keeps it for signature of the doctor. After that, the prescription becomes valid. However, this does not apply to e-prescriptions. The manually written prescriptions are usually difficult to read and only the pharmacist who is in touch with the prescription can read and decipher the details mentioned in the prescription. There is a possibility of serious misjudging of the prescription and wrongly dispensing due to legibility issues. However, including e-prescriptions, there is a need to review every medication to scrutinize the relevance of indication and dose for appropriateness and correctness.
2.What are the kinds of prescription errors observed in the clinical practice?
Prescriptions are written by doctors after diagnosing the disease. In many cases, each drug may be an indication to mitigate a particular symptom or correcting the physiology of the patient. Several times, it is possible that a single drug may be acting to mitigate more than one symptom. For example, NSAIDs are known to reduce fever and relieve pain. If there are more than one medicine of pain and fever, prescribing an additional drug will increase the drug burden for the patient. There can be a prescription for which there is no indication. The doses of a particular drug maybe wrongly mentioned in prescriptions. There can be a problem due to look alike and sound alike nomenclatures of drugs.
3.Define patient safety and how it should be achieved 1?
Patient safety is a practicing philosophy in which the healthcare providers dedicate themselves to give freedom from injuries and hazards arising during treatment. It can be achieved by commitment of the leaders of healthcare providers and patient education e.g. the hand-wash strategy to control the occurrence and spread of resistant infectious diseases.
4.How the patient safety can be endangered by wrong prescriptions?
The prescription may be illegible and may contain a drug which is hepatotoxic and nephrotoxic. Each drug may have several steps of instructions needed to be followed to optimize the outcomes of therapy. In such circumstances, the patient safety if not observed may lead to a drug induced ADR causing discomfort to the patient. If the prescription contains antacids and tetracyclines it can lead to poor absorption of tetracyclines due to formation of complex of tetracycline-antacid.
5.What is the role of pharmacist in prescription scrutiny?
The pharmacist after receiving the prescription reads it with a critic bent of mind and tries to scan from the principles of pharmaceutical care. In this exercise, he checks for duplication whether by oversight the medicines belonging to the same therapeutic category are contained in a prescription. He also checks for drug-drug interactions along with drug-food interactions which are likely to occur if the spacing of administration time is not suggested. It also calls upon the cooperation of doctors and nurses to alert timely in confidence and explains the patient to minimize the drug-drug interactions by avoiding the administration of both the drugs together.
6.How to manage a prescription scrutiny in a hospital or community pharmacy?
The modern computer system allows easy access to information and there is a need to utilize this knowledge for scrutiny of prescriptions from the point of indication of medicines, drug-food and drug-drug interactions. The review of patient medication history can give an idea regarding drug allergies and ADR history in patient. This would be a valuable service to patients.
7.Why prescription scrutiny is not given importance in clinical practice?
The conventional belief by care-provider assuming responsibility of ownership of bad outcomes makes it difficult for a hospital or practitioner to admit any controversial outcomes which are usually not made public. As the scrutiny, a routine approach by pharmacist may become repetitive and boring as most of the time they would come out with no major fallacies in prescriptions. The prescription scrutiny is also not linked to any financial incentives and rewards; one would lose interest in prioritizing the prescription scrutiny. In many circumstances, prescription scrutiny is viewed as academic pursuit rather than practice.
8.What are the skills required for prescription scrutiny?
The background of pharmacist involves basic health sciences, applied pharmacology along with pharmaceutical sciences. The pharmacist angle of prescription scrutiny stems from these above faculties and also from experience of work in clinical, hospital and community settings. The pharmacist needs to be skillful in analyzing the prescription from the angle of practical implications on administration of drugs in prescription. He should also be able to judge any severe violations as for errors in prescriptions. The dosage scan should be acquired by training in posology. Communication skills should be sharp enough to interact with the patient in a professional manner.
9.What are the benefits of prescription scrutiny for different stakeholders?
The prescription scrutiny brings out the discrepancies in prescriptions and offers an opportunity to correct the anomalies, thus acting as a preventive approach to ensure best practices in patient safety and efficacy. The benefits shall be shared by whole healthcare team in terms of better outcomes and preservation of resources.
10.Explain the major prescription only medicine related patient safety issues2.
The prescription only medicines (POM) are potential enough to cause drug-induced injuries in the patients. That's why they are bound by separate set of legal framework which confines the custody of POM to a registered pharmacist. Pharmacists are supposed to keep these medicines away from public and should only dispense to the public on receipt of valid prescription. If the POM is made available to the community members, they are likely to misuse without consulting the doctor or pharmacist. Open easy access to POM is illegal and dangerous. They should be used under the guidance of healthcare providers as they are backed by technical information and guidelines regarding how to use them.
11.What should be the incentive package and requirements of establishing patient safety programs?
The patient safety programs are undermined due to stigma associated with healthcare provider's efficiency to treat patients. The incidences of patient safety violation never come to light as healthcare provider doesn't like to get noticed by media as this would jeopardize the career opportunities. On the other hand, if the approach in the system to identify and classify the root cause of patient safety issue, then there can be change in attitude of healthcare providers. Instead of pinning the responsibility of patient safety violation on an individual healthcare provider it would be better if the holistic systemic approach can act as an incentive for reporting and resolving patient safety programs.
12.What is the ethical support for conducting prescription scrutiny in a healthcare system?
The errors in the prescription can cause negative outcomes and harm patient's health. Errors are bound to happen as healthcare delivery is multidisciplinary with lots of communication gaps. This can be managed by adopting the instruments like prescription scrutiny as this program would try to identify the error rather than pointing an error to a fellow healthcare provider in the best interest of the patient welfare.
13.What is the legal status for practice of prescription scrutiny?
The pharmacist's professional responsibility involves the patient safety as a major activity. In case lapse of duty by pharmacist can lead to prosecution of pharmacist for professional negligence of duty. The pharmacist is supposed to check the appropriateness of drugs, doses and instructions of physicians mentioned in prescription before dispensing. In case any patient safety issue is suspected to arise, he must confidentially draw attention to the issue with the prescriber explaining him consequence of the treatment. This way he can prevent a casualty and contribute to the treatment.
14.What are the steps to be taken to ensure patient safety in clinical settings3?
The pharmacist in the routine ward rounds visits each patient bedside and studies the prescription notes. He then makes his observations and subjects the details of the prescription to drug interaction protocol. In case he comes across any unusual thing happening to patient, raises an alarm and informs the nurses and the physicians to take appropriate measures to avoid further casualties.
15.Differentiate the patient-safety practice in community and clinical practice.
Environment settings of community and clinical differ by the nature of the patients and their expectations. In community setting, patients are ambulatory and are not so serious condition and are procuring the medicines. Whereas in clinical settings, patients are under serious condition and are admitted in hospital who needs to be provided with nursing and physician care. The community pharmacy setting, the pharmacist needs to be vigilant regarding the dispensed medications and should try to alert the patient or patient assistant. For example, if patient is dispensed with antihistamine cough mixture, the pharmacist should alert the patient regarding the drowsiness side effect and advise the patient from driving or any machine related operations. However in clinical setting, the team of nurse, pharmacist and physicians are involved in giving patient care as a team and the pharmacist should be able to intervene the treatments whenever drug related issues are causing harm to patient.
16.Give the classification of patient safety measures which can be adopted in clinical pharmacy?
The clinical pharmacy practice involves services for in-patients and patients who are getting discharged from the hospitals. For in-patients, the scrutiny of medication review and observation for any signals in patients due to ADR is the major responsibility of the clinical pharmacist. The clinical pharmacist needs to be vigilant for errors in drug administration and prescription. For this, they need to collaborate with nurses and doctors. In discharge medication review, the pharmacist should plan and implement in dialogue with the patient. It is also required to advise the patient to come for review of plan to identify and correct any patient safety issues.
17.Give the classification of patient safety measures which can be adopted in community pharmacy?
The community pharmacy is recognized by the patient himself and visits trusted pharmacies as patient is confident about the pharmacist. The patients seek advice regarding health and disease condition and ask the pharmacist to give medicines. The community pharmacist should be able to judge whether the patient is having a minor ailment for which there is no elaborate health checkup needed. He can advise the patient and dispense OTC medications under informed self medication. Further if the patient is having a major condition, he must alert the patient to see a doctor or go to hospital as the condition is serious.
18.How to communicate the error in a prescription to the prescriber?
The prescriber is a doctor and is a team leader of therapeutics. He has prescribed medicines in a good faith to do beneficence to the patient but not the harm. The error in prescription might have not come to the notice of the prescriber. In such situation, it is the responsibility of the pharmacist to draw attention to the error if not corrected, the damage it causes to patients. This has to be resolved in a skillful manner so that the image of the doctor never goes down in the patient's perception. He should communicate in a confidential manner and without raising alarm or criticism of the prescriber in front of the patient.
1. World Health Organization. Patient Safety. 2014; http://www.who.int/patientsafety/en/. Accessed July 24 2014
2. The Joint Commission. National Patient Safety Goals. 2014; http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed July 22 2014
3. National Patient safety Foundation. Key facts about patient safety. 2014; http://www.npsf.org/for-patients-consumers/patients-and-consumers-key-fa.... Accessed July 23 2014