Assessment of Prescription Writing Skills and Impact of an Educational Intervention on Safe Prescribing among the First-year Postgraduate Medical Students of Tertiary Care Hospital

INTRODUCTION

Prescription writing is an essential and basic skill to be acquired by a medical student during their undergraduate (UG) training. A prescription is a written order from the prescriber which gives a detailed instruction about the medicine to be given to a patient.¹

The word “prescription” comes from Latin word praescriptus meaning to write or to designate or order the use of drug as a remedy. World Health Organization (WHO) emphasizes on the inclusion of some essential components of prescription which are name, address of the prescriber, date of prescription, name and strength of the drug, dosage form, prescriber’s initials or signature, name, age, and address of the patient.² This information may come handy in case of an adverse drug reaction, so it is essential that prescription include complete information of the patient and the prescriber.³

Any mistake in writing a proper prescription leads to prescription/medication errors which may lead to inappropriate medication use and harm the patient. Prescription errors are caused by multifactorial reasons originating from both individual and organizational factors.³ Errors can be classified as either “new prescribing” or “represcribing”. New prescription involves a decision to start, stop, or change a drug, or its form, route, or dose. Re-prescription is any continuation therapy that includes prescriptions written when patients were admitted to hospital, transferred, or discharged.⁴ Prescription errors can arise from inappropriate choice of the drug, its dose, the route of administration, and the frequency or duration of treatment.⁵

Prescription writing is taught in the second year of medical school in India in pharmacology. The subject of pharmacology enhances the knowledge and skill of medical students about the different drug formulations and their usefulness in the treatment of various diseases.⁶ Even though the art of writing prescriptions is learnt during their second year, the de-learning starts once they enter their third-year clinics, which may be due to increased workload, casual attitude, and no fear of assessment. The reason for this callous attitude of the students’ needs to be rectified.⁷ Therefore, there is a need for proper education-based intervention throughout the UG course to aid improvement in prescribing competency. Thus, specific training and guidance should be mandatory during UG teaching, to avoid prescription-related errors in future practices and modifications in such UG training have shown a positive impact in prescription writing skills.^8–10 Also, the confidence and competence in prescribing can be increased through the use of targeted education programs.^9,11,12 There are many studies performed in the past, especially in foreign universities evaluating the prescription writing skills of junior doctors and medical UGs.^9,10,12–14

The present study evaluates the prescription writing skills of the first-year postgraduate (PG) medical students with the structured questionnaire. Also, the impact of educational intervention was assessed by analyzing a pre-session and post-session prescription.

MATERIALS AND METHODS

A cross-sectional study was conducted among the first-year PG students in a tertiary care hospital. The study was initiated after approval from the Institutional Ethics Committee. Written informed consent was taken from all the PGs participating in the study. The study sample included 58 PG students.

Student perception on how well their UG training has prepared them to prescribe were obtained using a preformed questionnaire. The questionnaire (Annexure 1) was pretested in the department of pharmacology with 25 students and questions were standardized. The testing and retesting of the questionnaire was performed. The questions were rephrased, reframed, added, and removed from the questionnaire for better comprehension. Most of the questions were of yes/no type. Few open-ended questions were also included. All participants were also asked to write a prescription for a common ailment, e.g., fever, in a given pro forma. After collecting the prescriptions, sessions on rational prescribing and the need and importance of the various components of the prescription were conducted. The prescriptions written by them were also evaluated and the feedback was given to the students to improve their prescribing knowledge for future. Post-session the students were asked to write prescription for the same case scenario. Their prescriptions both pre-session and post-session were analyzed.

The prescribing knowledge of the students was assessed based on the prescription’s quality, written in compliance with good prescribing pattern, and the WHO core prescribing indicators. The completeness of each prescription was assessed on the basis of two main components.¹

• Prescriber-related components
  • Prescriber information: Name of the prescriber, qualification, registration number, prescriber signature, date of the prescription, symbol R_x (“take thou”), and diagnosis.
  • Patient information: Patient name, age, gender, and address.
• Drug-related components: Appropriateness of the selected drug, strength of the drug, dose of drug, dose unit, dosage form, frequency, duration, route of administration, and directions for use.
• Other components analyzed: legible handwriting, information in capital letters.

RESULTS

A total of 58 PGs participated in this study. Table 1 depicts the analysis of feedback questionnaire. About 15.5% participants failed to acknowledge that prescription writing was systematically dealt during the second-year pharmacology teaching training program. Forty-five percent participants said that there were no questions asked in summative assessment regarding prescription writing, whereas it is a part of university requirement in practical examinations. When asked whether their UG pharmacology training had adequately prepared them to prescribe safely and rationally, 55% participants replied in affirmative and 49% participants replied that UG training had not prepared them for prescribing properly (Table 1 and Fig. 1).

When asked for the views and deficiencies regarding their UG pharmacology training and suggestions for its improvement, the most common comment of the students (72%) was regarding the futility of the pharmacology practical, especially in the animal experiments and pharmacy. The general suggestion was to replace these with pharmacology exercises having clinical application, to include bedside teaching, and to make the teaching more interactive and interesting using clinical scenarios (Table 1 and Fig. 1).

Eighty-six percent participants agreed that they had written a formal prescription to a patient before. Nearly 50% participants agreed that clinicians discussed prescription writing but only during the clinical case discussions. Twenty-nine percent participants said that these discussions happened more often and regular, whereas 21% participants felt that such discussions were rare, which implies that the training of prescription writing is more of a case discussion event. More than three-fourth of the participants (83%) accepted that such discussions and hands-on training by clinicians help in better prescription writing. Ninety-one percent participants said reinforcing classes during the third, fourth year, and during internship (Table 1 and Fig. 1).

Seventy-nine percent participants preferred generic name while prescribing but 21% participants preferred trade name. Forty-nine students said that they provide patient education and counseling on discharge. Majority of the PG students were not confident in prescribing for special patient groups, such as pregnant women, children, elderly, and in patients with hepatic/renal disease. Most of them (86%) had neither worked in collaboration with pharmacy/pharmacist nor dispensed medications, though they were aware of the role and functions of pharmacy services (Table 1 and Fig. 1). As per our findings, the different sources of drug information were books (53), internet (36), journal (9), teachers (9), practitioner (4), MR (7), drug leaflets (5), seniors (2), media (3), friends (1), newspaper (1), and website like 1mg.com.

Analysis of prescriber information was performed; it was found that the prescriber name, qualification, registration number, and signature were missing in 83%, 93%, 95%, and 73% of the prescriptions, respectively. After the educational intervention, there was a significant decrease in the percentage of such errors (33%, 57%, 30%, 11%; Table 2 and Fig. 2). Symbol R_x was missing in 26% of the prescriptions. Diagnosis and date were not mentioned in 57% of the prescriptions. Post-session significant improvement was seen (9%, 43%, 36%; Table 2 and Fig. 2). Patient name and age were not written in 69% of the prescriptions. Gender and address of the patient were not mentioned in 73% and 93% of the prescriptions, respectively (Fig. 2). Post-session there was a significant improvement in the patient-related information (Table 2 and Fig. 3).

Majority of the participants selected appropriate drugs for the given case scenario. Most of the participants had written the drug by generic name. Dosage form, dose, frequency, duration, and route of administration of the drugs were not mentioned in 57%, 52%, 45%, 64%, and 93% of the prescriptions, respectively. Some prescriptions had unauthorized abbreviations such as T or T/b for tablets, C or CP for capsules, and O/D for once daily dosing. Significant improvement was seen in the drug-related components post-interventional sessions (Table 2 and Fig. 4).

Handwriting was legible and comprehendible in all of the prescriptions. Eighty-six percent of the prescriptions lacked information in capital letters, which improved significantly post-intervention. Though during the discussion everyone had the opinion that patient’s need to be instructed about the use of medication but only 33% of participants had written such patient instructions after the intervention (Table 2 and Fig. 4).

DISCUSSION

Prescription for common ailments is an important core competency of a medical UG.^11,15 It involves a mixture of knowledge, judgment, and skills.¹⁶ The present study was undertaken for the assessment of knowledge, attitude, and practice of prescription writing pattern as per new Medical Council of India (MCI) guidelines. The study also sought to identify the areas in UG pharmacology education which PG students considered to be deficient and inadequate. Though all medical UGs get the prescription writing training during their second phase of MBBS, but in the present study, we noted 16% of the participants saying that they never had such training. The reason could be curriculum difference among different medical colleges. These results were consistent with the study conducted by Upadhyaya et al. where 86% of residents said that they were taught prescription writing in the UG pharmacology training.⁶

Many studies opine that once the newly qualified doctors are exposed to workplace prescription writing, they retrospectively feel that there was insufficient emphasis on practical aspects of writing prescription in UG curriculum.^11,17 As per the findings of our study, 26 (49%) participants replied that their UG pharmacology training has not prepared them to prescribe safely and rationally. Most of the participants rated their present knowledge of pharmacology to be average. Our findings correlate with similar studies conducted in India and in neighboring countries.^6,18 There was another study conducted in which significant proportion of the participants agreed that their UG education had not prepared them suitably to prescribe safely and rationally, and rated their knowledge of clinical pharmacology as poor suggesting the need for improved, focused, and well-structured clinical pharmacology teaching.¹⁷ Introducing bedside teaching, making the pharmacology practical more clinically relevant, using clinical scenarios to make teaching more interactive and interesting, and the introduction of newer teaching methods to improve the retention of knowledge were the common suggestions of the study participants which also have been suggested in the other previous studies.^18–22

Implementing problem-based training in pharmacotherapy in UG medical education based on national standard treatment guidelines has also been recommended as an important intervention to improve prescribing.²³ In previous studies conducted in India interns wanted the pharmacology curriculum to be extended and integrated with the final year clinical subjects.^19,21 Similar in our study also 91% of participants said reinforcing classes of pharmacology during the third, fourth year, and during compulsory rotatory residential internship will be more beneficial. In many medical schools in developed nations, pharmacology is taught throughout the UG course.²⁴ The benefits of the integration have been widely reported and the method has been recommended by the WHO as a core intervention to promote rational drug use.²⁵

Our results also reveal that only a small number of students (14%) were confident to prescribe to special patient groups, such as pregnant women, children, elderly, and patients with hepatic and renal impairment and majority felt difficulty in prescribing for special group. Another study by Upadhyaya et al. also shows similar result.⁶ According to a well-executed study in UK, it was found that confident prescribing to special patient groups was directly associated with specialist ward attachment and exposure to special patient groups in a hospital setting.¹⁷ Our participants’ lack of confidence might be due to a deficiency in their training and the lack of clinical or applied aspects of prescribing to these special patient groups.

Information regarding the prescriber was missing in many prescriptions. The prescriber name and signature were missing in 83% and 73% of the prescriptions, which is also reported by Khan et al. (77%) and Dharmadikari et al. (82%).^26,27 Participants in many studies, including ours, failed to mention their phone numbers and addresses.²⁸ Such contact details may be lifesaving if patient faces adverse drug reactions. In India, it is mandatory to mention the registration number in each prescription. The lack of the display of registration number may amount to serious negligence on the part of the doctor. In our study, the prescriber registration number was missing in 95% of the prescriptions, which is more as compared to the other studies where it was 85%.^26,29 There was another study which showed that the use of personalized stamps bearing the prescriber name and registration number was a useful and inexpensive method to improve the quality of the prescriptions.³⁰

On further analysis, in 57% of the prescriptions, dates were not written, which is less as compared to the study by Khan et al. (81%).²⁶ Presence of dates in the prescription is useful in monitoring the drug therapy and also during drug refills. Diagnosis, the most vital component of a prescription, was missing in 57% of the prescriptions, as was also noted in another study.²⁹ Failure to mention the diagnosis can cause problems during the follow-up visits. However, there was a significant improvement in the knowledge about the physician-related components of the prescription after the educational intervention. According to the WHO, these elements are very essential while writing a prescription and are also very helpful to the pharmacist to clarify any doubts by contacting the prescribers.¹³

Lacunae were also observed in writing the patient information. Patient name, age, sex, and address were missing in 69%, 73%, and 93% of the prescriptions, respectively. The presence of name and address is useful in locating the patient in case of any prescribing or dispensing errors. Mentioning the age of the patient is a legal requirement, especially in children below 12 years. It is also essential to mention the gender of a patient, as drug response differs in male and female population. Such deficiencies were also reported in other studies.^27,29 However, there was a significant improvement in writing the patient information after the educational interventional sessions.

Deficiencies were also noted in writing the drug information in the prescriptions and this was observed in few studies performed in the past.^27,29,31 In the present study, the students were able to select appropriate drugs for the given case scenario, as the case chosen was very easy and common. In our study, even though many participants (79%) knew that generic names are to be used (according to questionnaire analysis), still 62% of the students wrote generic names and this percentage increased to 93% after the educational intervention. In a study performed by Sukhlecha et al., only 19.6% of the drugs were written in generic names and in another study, 100% of the drugs were prescribed by the brand names.^32,33 Though the branded drugs are costlier, but they can be used when problems of bioavailability are expected. The generic drugs are cheaper, so prescribing generic medicines rather than branded products will help in reducing healthcare cost.³⁴

Also, the recent (2016) MCI guidelines insist on writing drugs with generic names only.³⁵ Students can make use of the official formularies, such as the National Formulary of India, Cochrane database for choosing appropriate drugs.³⁶

On further analysis, it was noted that the dose of the drugs were written incorrectly in 22% of the prescriptions. This may cause serious consequences, in case adult doses are written for geriatric or pediatric patients. The strength of the drug was not mentioned in 21% of the prescriptions, similar observations were made in another study.²⁶ Writing drug strength is vital, as pharmaceutical products are available in different strengths. In 57% of the prescriptions, dosage forms of the drugs were missing. Writing appropriate dosage forms are essential to achieve desired therapeutic response. Omissions in writing the frequency of drug administration were noted in 45% of the prescriptions. This can contribute to toxicities and treatment failures. Irrational, ineffective prescribing can lead to needless polypharmacy, drug resistance, and drug interactions.³⁷

None of the students wrote the directions for use for the patient in this study which is comparable to another study where it was missing in 98% of the prescriptions.²⁶ This may be due to the reason that all the drug-related instructions (e.g., taking drug before or after food, during day time, before bedtime, etc.) are usually explained to the patient verbally. However, during the session, the facilitators explained the students regarding the importance of writing instructions on the prescription to minimize medication errors.

Consequences of common prescribing errors, such as inappropriate drug, dose or units, lack of awareness of drug interactions, choosing two drugs belonging to the same class, choosing wrong routes to give medications, infusions with no clear details of diluent, rate, and most importantly calculation errors, especially in pediatric prescriptions were explained in detail to the students during the educational interventional sessions. Improvement was seen in writing the drug information part after the educational intervention sessions. Similar observations were seen in another study, where attending a 1-hour interactive session by the medical students decreased the frequency of prescribing errors.¹⁰

Illegible handwriting may lead to serious medication error as has been reported in many of the previous studies.^30,38,39 Contrastingly, in our study, handwriting of all the participants was legible and comprehendible and 14% of participant wrote drug-related information in capital letters and this number increased to 79% after educational intervention. The importance of legible handwriting and the completeness of the prescriptions were explained in detail by showing them examples of illegible prescriptions and medication errors which occurred due to the lapses in prescription writing. According to the MCI guidelines, all the drug-related information should be preferably written in capital letters in a prescription.³⁵ In a study conducted by Saravanan et al., 68% of the students agreed that computerized prescriptions with the use of a standard prescription format will be helpful to avoid prescription-related errors. As they will have clear legibility and precise information about the drugs.^30,40 However, in developing country like India, due to financial constraint, lack of adequate skilled manpower, it may not be possible to implement it to each and every healthcare center, so it becomes important for the practitioner write the prescription legibly keeping in mind all the instructions and guidelines suggested by medical governing body.

The use of abbreviation for writing prescription of drug was 29%, whereas study performed by Kumari et al. showed 69.8% of interns using the abbreviation for writing the name of a drug in prescription writing.⁴¹ Inaccuracy in writing, illegible handwriting, the use of abbreviations or incomplete writing of a prescription, can lead to misinterpretation of prescription at various levels.⁵

There is growing evidence that, prescription errors are increasing and are often caused by inadequate training in prescription writing.³ It has been seen that educational interventional sessions were useful in improving the prescribing competencies of the medical students, by training them with the WHO guide to good prescribing.⁴² Educational interventional sessions should be combined with giving feedback to the prescribers, as this will give an opportunity for them to learn from their mistakes and will also increase the effectiveness of learning.⁴³ These sessions should also be conducted for nurses and pharmacists. As this will aid in detecting prescription errors before dispensing or administering the drugs. Conducting training in the form of seminars, discussions, and hands-on training on drug-related problems was helpful in improving the prescribing skills of the medical students.⁴⁴

Various studies have suggested assisted e-learning modules brings about positive change in UGs regarding prescription writing.^38,45 Valid and reliable schemes of assessment on prescribing pattern should be introduced to ensure that the students have achieved the desired curricular outcomes.⁴⁶

CONCLUSION

Prescription writing should be identified as an important core learning competency. The quality of the healthcare system can be improved by writing a safe and rational prescription, for this a good theoretical and practical aspect of teaching in prescription writing is essential. In this study, several lacunae were observed in the prescription writing skills of the first-year PG students in which improvement was seen after the educational interventions in the form of theoretical lectures.

Our study also concluded that PG students were not aware of prescription writing guidelines by MCI and WHO prescribing indicators, therefore there is a perceived need for such reinforcement sessions to be held during the various phases of UG teaching. Revised pattern of pharmacology teaching, which is more learner-centered, clinically oriented, and well-integrated should be introduced. Such benefits of the integration have been widely reported and the method has been recommended by WHO as a core intervention to promote rational drug use.

LIMITATIONS OF THE STUDY

Limitation of our study is that the assessment was performed with clinical scenario which the students had studied as part of their curriculum. In this study, the main focus was on the basic components of the prescription, more elaborate sessions on rationality of prescribing needs to be conducted. Furthermore, follow-up research needs to be done to see the long-time effects of this training on the students in avoiding prescription errors.

Another limitations of our study was relatively small sample size as study was limited to the first-year PG students only and so the further studies can be pursued on different batches of the college and results can be compared.

ANNEXURE 1: FEEDBACK QUESTIONNAIRE

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