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Table of Contents    
GUEST COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 4  |  Page : 928-933

Rational approach to prescription writing: A preview


Department of Pharmacology, Maulana Azad Medical College, New Delhi, India

Date of Web Publication18-Jul-2018

Correspondence Address:
Dr. Bhupinder Singh
Department of Pharmacology, Maulana Azad Medical College, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.236960

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 » Abstract 


Prescription writing has to be properly addressed with regard to its correctness and appropriateness. Any errors in the procedure have to be eliminated. Electronic prescribing has abolished most of typographical prescription errors but the rationality involved in prescription of drugs is more of a thought process, which is still not optimum. Irrationality in prescriptions leads to medication errors causing increased morbidity or hospitalization and an economic loss. The rational use of medicines should be practiced which begins with defining the therapeutic objective, choosing the right medicine which is specific to the patient's needs, followed by monitoring of response to therapy. Compliance and outcome of therapy is totally dependent upon the doctor-patient relationship, a proper information and communication with the patient, and the physician's commitment and empathy towards the patient.


Keywords: Medication errors, prescription writing, rational use of medicine
Key Message: Technicalities of prescription writing have been addressed previously but rationality in prescription writing is also of prime concern. This review is an attempt to lay stress on the practice of the rational use of medicines in prescriptions. Morbidity occurring because of irrational and inappropriate prescriptions can be curbed with education and awareness of the prescriber.


How to cite this article:
Batta A, Singh B. Rational approach to prescription writing: A preview. Neurol India 2018;66:928-33

How to cite this URL:
Batta A, Singh B. Rational approach to prescription writing: A preview. Neurol India [serial online] 2018 [cited 2018 Oct 22];66:928-33. Available from: http://www.neurologyindia.com/text.asp?2018/66/4/928/236960


Prescription writing has often been addressed with regard to its correctness and appropriateness, higlighting the errors associated with it. Electronic prescribing has abolished most typographical prescription errors but the rationality involved in the prescription of drugs is more of a thought process, which is still not optimum. Irrationality and lack of knowledge regarding the art of prescription writing often leads to medication errors, causing increased morbidity or hospitalization and economic loss. The rational use of medicines should be practiced that begins with defining the therapeutic objective, choosing the right medicine which is specific to patient's needs, followed by monitoring of the response to therapy. The compliance and outcome of therapy is entirely dependent upon the doctor–patient relationship, the dissemination of proper information, an appropriate communication with patients, and the physicians' commitment and empathy toward their patients.

The word “prescription” originates from the two words “pre-” (“before”) and “script” (“writing, written”) and refers to an order that must be written down before a drug can be dispensed. A prescription order is written for the diagnosis, prevention or treatment of a specific patient's disease. It is written by a licensed practitioner. It is written as part of a proper physician–patient relationship. It is a legal document, and may be used as prima facie evidence in a court of law.

In the ancient era, the pharmaceutical industry was nonexistent. The compounds or medicines along with their appropriate amounts were mentioned by physicians on prescriptions, with instructions to pharmacists for dispensing the medicines in appropriate doses and amounts. Thankfully, this job of compounding and dispensing of medications has been taken up by the pharmaceutical industry. Presently, medicines along with their dose and duration of intake are directly mentioned on the prescription itself. Globally, medicines are dispensed by pharmacists as per the doctor's prescription.

Parts of prescription

The individual sections on the prescription consists of the prescriber's details, the patient's details (name, age, gender, address), the superscription, the inscription, the subscription, and the signa [Figure 1].[1]
Figure 1: Parts of a prescription

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  1. Prescriber's details: It consists of the name, address, registration number, and contact number of the treating doctor. The importance of having the prescriber's details on the prescription is for the benefit of the patient:


    1. To contact the doctor in case of emergency or adverse drug reaction
    2. The registration number of the doctor is clearly written and is an assurance for the patient that the prescriber is registered with a medical council. This reflects the authenticity of the doctor.


  2. Superscription is represented by a symbol Rx [Figure 2], which is always written at the beginning of the prescription. The symbol Rx represents a prescription order. In ancient Egypt, this symbol was written on prescriptions as a prayer to the God of healing. Rx is also a symbol for the eye of Horus [Figure 3]. Horus was an Egyptian God who had his eye damaged and taken out of him. He had his eye healed by another god and Horus then gave his healed eye to his dead father to bring him back to life. In the days of mythology and superstition, the symbol was considered as a prayer to Jupiter, the God of healing, for the quick recovery of the patient. In Latin, it means “recipe” or “take thou,” that is, “you take”
  3. Inscription is the main body of the prescription. It contains the names and quantities of the prescribed medicines. Physicians are supposed to write the generic name of the drug prescribed by them, its dose, frequency, and the duration of therapy. This part of prescription is the most important area where the physician has to be very careful and vigilant. His knowledge about the medicines and his competence is reflected by what and how he writes
  4. Subscription is the part of the prescription that contains the prescriber's directions to the pharmacist regarding the dosage form and number of doses to be dispensed. Alternative medicines, refills or change of brands as directed by the physician are mentioned under this section. The pharmacist has to be careful while dispensing medicines with regard to the quantity and duration of therapy. Drugs that come under schedule X, as well as other controlled substances, should be dispensed based upon the instructions in the prescription. Pharmacist should be vigilant regarding the date of prescription as some patients try to procure drugs with a potential for abuse for recreational purposes
  5. Signatura/signa is usually abbreviated as “Sig” on the prescriptions and consists of the directions to be given to the patient regarding the administration of the drug. It usually indicates the quantity of the medicament or the number or dosage units to be taken, the number of times in a day the medication has to be ingested, the relationship of its timing of intake to the meals taken, and the manner in which it is to be administered or applied. It also includes follow-up instructions and specific advice related to diet and lifestyle modifications and other nonpharmacological measures
  6. Date: The inscription of date on the prescription is not only important for the patient but the prescriber and the pharmacist as well. With regard to the patient, it helps to ascertain the course of therapy, the timing of follow-up required, and it also serves the purpose of aiding as medico-legal evidence in the court of law. From the doctor's viewpoint, it indicates the compliance to treatment, helps in determining the validity of the prescription and in avoiding unnecessary redispensing of the medication described in the prescription. The pharmacist cannot identify an old prescription brought for redispensing of medication, if it is not dated.
Figure 2: Rx symbol

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Figure 3: The eye of Horus. Attribution: By Jon Bodsworth [Copyrighted free use], via Wikimedia Commons. https://commons.wikimedia.org/wiki/File: Wedjat_(Udjat)_Eye_of_Horus_pendant.jpg

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Last but not the least, prescription should be signed and dated. The onus lies on the prescriber for being responsible for the facts mentioned in the prescription. Hence, it is important to safeguard one's interest; the prescriber should be well acquainted with the art of writing a prescription. There is no margin for any error as a prescription directly deals with the patient's well-being and life.

Rational prescribing

Writing a prescription should be based on a series of rational steps [Figure 4]:[2]
Figure 4: Flowchart for writing a rational prescription

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  1. Define the patient's problem: Careful listening to the patient's problem is vital in making a diagnosis. For example, a patient complaining of cough, fever, and fatigue is usually taken as having an ailment of viral origin and treated for the same. Fatigue is a very significant but often the most neglected symptom. It is indicative of heart failure or diabetes mellitus and should always be investigated
  2. Make a specific diagnosis: It is necessary to make a diagnosis, even if it is presumptive, as it is mandatorily required to move on to the next step. The line of pharmacological therapy is totally dependent on the diagnosis made in the prescription
  3. Consider the pathophysiologic implications of the diagnosis: If there is a good understanding of the disease, the prescriber is in a much better position to prescribe effective medications. The patient should be provided with the appropriate level and amount of information about the pathophysiology. It has been observed that compliance with the prescribed therapy improves if the patient understands the implication of the disease
  4. Select a specific therapeutic objective: A therapeutic objective should be made for each of the pathophysiologic processes defined in the preceding step. In a patient with angina, achieving a relief of chest pain by coronary vasodilatation, and a decrease in the work of heart, are the major therapeutic goals that identify the group of drugs that should be considered appropriate for the patient. Arresting the course of the disease process in angina is a different therapeutic goal, which might lead to consideration of other drug groups and prescriptions
  5. Select a drug of choice: A single drug or multiple groups of drugs are usually indicated for each therapeutic objective. Selection of a drug of choice from among these groups requires consideration of the specific characteristics of the patient and the clinical presentation. For certain drugs, characteristics such as age, other comorbid conditions, and concomitant medications being taken are extremely important in determining the most suitable drug to be chosen for treating the present complaint. Selection of the drug is based on four important criteria, efficacy safety, suitability, and cost. Efficacy is the most important parameter or decisive factor for choosing the drug of choice. Suitability refers to the selection of appropriate dosage and formulations, while keeping the patient's characteristics and presence of any contraindications of the medications in mind
  6. Determine the appropriate dosing regimen: Dosing and duration of therapy is disease specific and is determined by the pharmacokinetics of the drug. It is extremely important to assess the hepatorenal status of patient while administering some drugs. The clearance of the drug from plasma is slow in patients with a compromised hepatorenal status leading to toxicity [Table 1] and [Table 2].[3],[4],[5],[6] Physician should be watchful while prescribing medication to pregnant and lactating women [Table 3].[7],[8] Drug–drug interactions must be thought of in case of polypharmacy [Table 4][9]
  7. Monitoring of drug therapy: The prescriber should be able to explain to the patient the kinds of drug effects that need to be monitored. The patients should also be informed regarding the laboratory tests necessary at appropriate times, and the development of signs and symptoms of the disease or the medications administered that the patient should report. For illnesses that require a short course of therapy (e.g., most infections), the duration of treatment should be explained to the patient as he/she might erroneously assume that the medication is no longer needed because the bottle is empty or that symptomatic improvement has occurred. For a patient with a prolonged illness, e.g., bronchial asthma, the need for a prolonged therapy should be explained. The prescriber should also specify to the relatives of the patient to look for any changes in the patient's condition that might require a change in therapy. Major toxic reactions that require immediate attention should be explained to the patient.
  8. Patient education: The prescriber and other health-care professionals should be prepared to repeat, extend, and reinforce the information transmitted to the patient as often as is necessary. The more toxic the drug prescribed, the greater is the importance of this educational program. Informing and involving the patient in each of the above steps is mandatory.
Table 1: Some important drugs either contraindicated or requiring dose adjustment in renal dysfunction

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Table 2: Some important drugs contraindicated or requiring dose adjustment in hepatic dysfunction

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Table 3: Drugs contraindicated in pregnancy and lactation

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Table 4: Some important clinically significant drug-drug interactions by cytochrome P-450 enzymes

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Errors in prescription writing

Prescription writing is not just putting some words on a piece of paper. A systematic and meticulous approach should be followed while writing a prescription. A prescription can be illegible, incomplete, and irrational. Illegible or unreadable drugs are the biggest challenges as they lead to a large number of prescription errors. It is the eighth leading cause of death in the United States with more than 98,000 people dying because of it annually.[10] The National Patient Safety Agency revealed that medication errors in all care settings in the United Kingdom occurred in each stage of the medication treatment process, with 16% errors occurring in the prescribing, 18% in the dispensing, and 50% in the administration of drugs.[11] In India, studies done in Uttarakhand and Karnataka have documented the medication errors rate in hospitalized patients to be as high as 25.7% and 15.34%, respectively.[12]

Incomplete prescriptions are prescription orders with missing or inappropriate information, that is, the dosage form, the route of administration, the dosing schedule, the duration of therapy, etc. Prescriptions without signature of the prescriber, a review advice, instructions to patients, refill instructions, etc., are also considered to be incomplete. This can lead to more of guess work on the part of both the pharmacist and the patient, which may lead to a fatal outcome.

A rational prescribing is to be adopted where in the right drug is to be prescribed for the right diseases, for example, the usage of antibiotics in viral disorders, and the usage of irrational fixed dose combinations such as ciprofloxacin and metronidazole should be avoided.

Medication errors

Many medication errors occur as a result of poor prescribing of medications and are due to the presence of ignorant medical staff members. The causes for medication errors can vary from a miscommunication between the physicians, patients, pharmacists, and other paramedical staff who are involved; the improper storage, labeling, packaging of medications; confusion regarding 'look-alike sound-alike' (LASA) drugs; lack of information on current pharamacological trends, protocols, dosing, references, and medicine formularies; and, the prevalent unawareness among the staff members regarding new medicines, narcotics, or high-alert medications.

Other than this, causes of prescription errors include human factors such as excessive workload, fatigue, inexperience, lack of training, and poor handwriting; workplace factors such as poor lighting, noise, interruptions; pharmaceutical factors such as polypharmacy, confusing drug nomenclature, packaging or labeling, increased number or quantity of medicines per patient, and an increased frequency and complexity of calculations needed to prescribe, dispense, or administer a medicine; and, lack of standard operating procedures (SOPs).

At the patient level, the individual's understanding of the prescriber's instructions and the level of compliance affect the outcome. An intellective communication on the part of prescriber in making the patient comprehend the prescription is again an important factor that is helpful in reducing prescription errors.

Medication errors have a huge and an equal impact on the health-care system, the patients, and the personnel responsible for bearing the expenses of the medications. These errors compromise the confidence levels of patients on the health-care system that they are an integral part of.[13]

Steps to be taken to minimize prescription errors

  1. Electronic prescriptions: These can reduce the risk of prescribing errors owing to illegible handwriting. Clumsy handwritten prescriptions should be replaced by computerized physician order entry, a very effective technique for reducing the prescribing errors. Corporate hospitals are already E-prescribing and also maintaining records, along with patient details. The issue mainly remains with government hospitals where handwritten prescription are still being written
  2. Emphasis on a legible handwriting and complete spelling of the medicine's name in block letters; and, using standardized notations, appropriately mentioning dosages, using leading zero for values less than one, and no trailing zero (e.g., 0.2 mg instead of. 2 mg; 2 mg instead of 2.0 mg) are useful measures to minimize errors
  3. Mentioning the route of administration on all prescriptions as well as completely written directions, are necessary steps. Avoiding the use of telephonic and verbal orders in emergencies; confirming the identity of patients before administering medication; for LASA names, establishing a policy that requires that prescribers to write both the brand and generic names; and, recruiting the pharmacy staff to help in preventing errors, are useful steps.[14],[15]
  4. Steps to increase the awareness of prescription errors among health-care professionals are necessary
  5. Steps to encourage medication error reporting systems, and especially encouraging health-care professionals to report medication errors are necessary
  6. Conduction of regular educational and training programs, such as workshops, on prescription writing for interns and postgraduate students are necessary
  7. Training and educating pharmacists are also mandatory steps
  8. Teaching the art of prescription writing to undergraduate students is essential. This practice should be a part of their teaching curriculum.


Nonadherence to therapy

Adherence to therapy is the extent to which the patients follow treatment instructions. The causes of medications errors may be due to the following factors:

  1. The patient fails to take the medication as prescribed. Examples include improper dosage, improper frequency, wrong timing, or sequencing of administration, wrong route of administration, or taking medications for the wrong purpose. This usually results from a poor communication between the patient, the prescriber and the pharmacist
  2. The patient prematurely discontinues his medication. This is due to lack of effect of the medication or an adverse drug reaction
  3. The patient takes medication inappropriately. For example, the patient may share a medication with others, may not be following the dosing schedule, may be stopping medication before completion of the course of therapy
  4. The patient fails to obtain the medication. Some studies suggest that one third of patients never obtain their medications based on their prescriptions. Some patients leave the hospital without obtaining their discharge medications, whereas others leave the hospital without having their prehospitalization medications resumed. Some patients cannot afford the medications prescribed [2]
  5. Patients taking a drug once a day are more likely to be compliant than those taking a drug four times a day
  6. Patients living alone are less likely to be compliant than married patients of the same age. Various social or personal beliefs about medications can become barriers to compliance [2]
  7. Poor understanding of instructions of the prescriber may also be an important factor.


Strategies for improving compliance

  1. A relevant communication between the patient and prescriber should be in place and an assessment of the personal, social, and economic conditions (often reflected in the patient's lifestyle) should always be considered while prescribing medicines
  2. Development of a routine protocol for taking medications (e.g., at meal times, if the patient has regular meals) should be established
  3. Provision of systems to assist in taking of medications (i.e. containers that separate drug doses by days of the week, for example, dosette boxes or medication alarm clocks that remind the patients to take their medications) should be in place
  4. The patient who is likely to discontinue a medication because of a perceived drug-related problem should receive instructions on how to monitor and understand the effects of the medication. Compliance can often be improved by enlisting the patient's active participation in the treatment.
  5. Repeated reassurance and the prescriber's faith in the therapy should be inculcated in the patient.



 » Conclusion Top


Many eventualities leading to morbidity and mortality can be prevented by adhering to good prescribing practices. Adopting the rational use of medicines and practicing evidence based medicine will benefit both the patient and the society.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
De Vries TP, Henning RH, Hogerzeil HV, Fresle DA. Guide to good prescribing: A practical manual. World Health Organization, Geneva. 1994. Available from: http://apps.who.int/medicinedocs/en/d/Jwhozip23e. [Last cited on 2018 Apr 09].  Back to cited text no. 1
    
2.
Katzung BG, Masters SB, Trevor AJ. Basic and Clinical Pharmacology. 12th ed. New Delhi: Tata McGraw Hill; 2012. pp 1039-48.  Back to cited text no. 2
    
3.
Björnsson ES. Hepatotoxicity by drugs: The most common implicated agents. Int J Mol Sci 2016;17:224.  Back to cited text no. 3
    
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Periáñez-Párraga L, Martínez-López I, Ventayol-Bosch P, Puigventós-Latorre F, Delgado-Sánchez O. Drug dosage recommendations in patients with chronic liver disease. Rev Esp Enferm Dig 2012;104:165-84.  Back to cited text no. 4
    
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Munar MY, Singh H. Drug dosing adjustments in patients with chronic kidney disease. Am Fam Physician 2007;75:1487-96.  Back to cited text no. 5
    
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Dhodi DK, Bhagat SB, Pathak D, Patel SB. Drug-induced nephrotoxicity. Int J Basic Clin Pharmacol 2014;3:591-7.  Back to cited text no. 6
    
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Burkey BW, Holmes AP. Evaluating medication use in pregnancy and lactation: What every pharmacist should know. J Pediatr Pharmacol Ther 2013;18:247-58.  Back to cited text no. 7
    
8.
Moretti ME, Lee A, Ito S. Which drugs are contraindicated during breastfeeding? Practice guidelines. Can Fam Physician 2000;46:1753-7.  Back to cited text no. 8
    
9.
Kalra B. Cytochrome P450 enzyme isoforms and their therapeutic implications: An update. Indian J Med Sci 2007;61:102.  Back to cited text no. 9
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10.
Salmasi S, Khan TM, Hong YH, Ming LC, Wong TW. Medication errors in the Southeast Asian countries: A systematic review. PLoS One 2015;10:e0136545.  Back to cited text no. 10
    
11.
Alsulami Z, Conroy S, Choonara I. Medication errors in the Middle East countries: A systematic review of the literature. Eur J Clin Pharmacol 2013;69:995-1008.  Back to cited text no. 11
    
12.
Patel N, Desai M, Shah S, Patel P, Gandhi A. A study of medication errors in a tertiary care hospital. Perspectives Clin Res 2016;7:168-73.  Back to cited text no. 12
    
13.
Karthikeyan M, Balasubramanian T, Khaleel MI, Sahl M, Rashifa P. A systematic review on medication errors. Int J Drug Dev Res 2015;7.  Back to cited text no. 13
    
14.
Laing R, Hogerzeil H, RossDegnan D. Ten recommendations to improve use of medicines in developing countries. Health Policy Plan 2001;16:13-20.  Back to cited text no. 14
    
15.
Samsiah A, Othman N, Jamshed S, Hassali MA, Wan-Mohaina WM. Medication errors reported to the National Medication Error Reporting System in Malaysia: A 4-year retrospective review (2009 to 2012). Eur J Clin Pharmacol 2016;72:1515-24.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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