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1 EVALUATION OF PRESCRIBING PRACTICES BY MEDICAL ASSISTANTS OFFICERS AT MALAYSIAN PUBLIC HEALTHCARE FACILITY Yee Siew Mei School Of Pharmacy, Division of Medicine, Pharmacy & Health Sciences, Taylor's University, Lakeside Campus, Subang Jaya, Malaysia Co-Author Dr. Mohamed Azmi Ahmad Hassali Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia

2 Introduction: Prescribing Errors “A clinically meaningful prescribing error occurs when, as a result of a prescribing decision or prescription writing process, there is an unintentional significant (1) reduction in the probability of treatment being timely and effective or (2) increase in the risk of harm when compared with generally accepted practice” Dean B. What is a prescribing errors. Qual Saf Health Care. 2002 Introduction Prescribers are human and thus make mistake. However, this type of medication mistake is preventable. Medication knowledge deficiency may attribute to prescribing errors. Since these types of medication errors are preventable, therefore it is an important target for improvement. Medication errors may arise from prescribing, dispensing, drug administration and patient compliance errors. Errors made during prescribing are the most common type of error and it is avoidable. Dean B. Prescribing errors in hospital inpatient. Qual Saf Health Care. 2002

3 Literature Review Background According to United States Pharmacopeia (USP) on the most recent report examines error trends over the five year period 1999-2003, the percentage of reported errors originating in the prescribing node has steadily increased from 11% (1999) to 23% (2003). Nearly 80% of the records were associated with the four leading types of errors (omission error, improper dose/quantity, prescribing error, and unauthorized drug). USP, Drug safety review. Medication error trends for 1999 – 2003 In European, 6.3 – 12.9 % of hospitalised patients have suffered at least one adverse event during their admission and that between 10.8 – 38.7% of these adverse events were caused by medications. 30.3 – 47.0% of these adverse drug events appears to be consequences of medication errors and therefore, maybe considered as preventable. In United Kingdom hospitals, prescribers make errors in 1.5% of prescriptions; and in primary care errors occur in up to 11% of prescriptions. Creation of a better medication safety culture in Europe: Building up safe medication practices, 2006

4 ReferenceSettingMajor Findings 1. Medical Error in MOH Primary Care Clinics Malaysia 12 MOH health care clinics in 4 states 93.4% medical errors preventable Medication error catered 41.3% 22.6% due to illegible writing AMOs saw 81% of total records accessed. Khoo EM et al. Medical errors in MOH primary care clinics KL Institute for Health Systems Research 2008 2. Outpatient Prescription Intervention Activities by Pharmacists in a Teaching Hospital Malaysia Teaching Hospital 54% omission error 46% decision error Chua SS et al. Outpatient prescription intervention activities by pharmacists. Malaysia J Pharm. 2003 3. Noncompliance With Prescription Writing Requirements and Prescribing Errors in an Outpatient Department Malaysia Teaching Hospital 96.7% omission error 8.4% decision error Kuan MN et al. Noncompliance with prescription writing requirements and prescribing errors in an outpatient department. Malaysia J Pharm. 2002

5 Most study on prescribing errors were carried out at western developed countries such as US and European targeting tertiary health care settings. In Malaysia there has been 1 study done on medical errors in 12 MOH primary care clinics. Another outpatient prescription intervention study was done in a teaching hospital, but the grade of prescriber was not identified. There has no study done on prescribing errors made by assistants medical officers (AMOs) in Malaysia primary health care clinics. AMOs are relied heavily on prescribing and assessing patients in primary health care clinics especially at remote area. Problem Statement

6 Aim & Objectives:  Aim: to evaluate the prescribing practices by AMOs at a public health setting in Malaysia  Objectives: to identify the frequency and nature of various types of prescription errors made by medical assistant to study the prescribing pattern of the medical assistant. to determine whether there is association between prescribing errors with patient’s demographic and disease stage. Aim & Objectives

7 Research Methodology  Study Design retrospective study 1 week Rx was collected and evaluated  Inclusion Criteria Any prescription regardless of diagnosis, duration, numbers of items prescribed, patient’s demography who was receiving treatment at Kampar Government Health Clinic and Kampar District Hospital. Prescription that was prescribed by medical assistant from Kampar Government Health Clinic and Kampar District Hospital.  Exclusion Criteria Prescription that prescribed by medical officer. Prescription that was not prescribed by medical assistant from Kampar Government Health Clinic and Kampar District Hospital. Research Methodology

8 Data Collection  Omission error Incomplete prescription Used of Abbreviation Illegible Hand Writing  Decision error Wrong indication Contraindication Polypharmacy Drug interaction Inappropriate Dosing Inappropriate duration treatment Inappropriate dosing frequency

9  there were 1169 prescriptions were screened and 421 prescriptions met the inclusion criteria Results Out of 421 prescriptions being studied, 97% were erroneous. There were in total 1169 errors found, representing 2.78 errors/prescription Error rate : 969 erroneous prescriptions with each 1000 new prescriptions generated. 67% : Omission error ; 33% : Decision error

10 Omission Errors (n=783) Type of ErrorsFrequency Inappropriate Abbreviation357 Patient Demographic3 Illegible Hand Writing34 Demographic & Frequency1 Demographic, Frequency & Dose3 Demographic & Dose2 Frequency1 Frequency & Dose25 Frequency & Duration352 Dose & Duration4 Duration1 Results

11 Decision Errors (n=386) Type of ErrorsFrequency Drug Interaction81 Polypharmacy81 Wrong Indication76 Inappropriate Dosing Frequency60 Inappropriate Duration of Treatment47 Inappropriate Dosing39 Contraindication2

12 Top 5 prescribed drugs with the highest number of errors

13 Incomplete Rx  93.1% (n=392) were incomplete with the information required. According to WHO Guide To Good Prescribing Practical Manual A Prescription should include: - Name, address, telephone of prescriber - Date - Name of the drug, strength - Dosage form, total amount - Name, address, age of patient - Signature or prescriber Discussion

14 According to Laurel et al, drug that was contraindicated to patient’s age catered for 8% of prescribing error. Taylor LK.The challenge and opportunity for patient safety. Healthcare Quarterly. 2005 Patient’s demographic especially the age is crucial although the absence would not prevent the dispensing. Prescribed in caution for paediatrics and/or geriatric patient. 83.6% (n=352) prescriptions with at least one medication which the dose was not noted completely. Eg: Tab piriton 1/1 tds Tab PCM 11/11 qid It may cause problem if the drug available in various strength. Absence of patient’s demographic Absence of drug information

15 There was 84.8% (n=357) prescriptions with at least one medication was written in abbreviated form. The nomenclature used for prescribing was found inconsistent and confusing. Terminology varies for individual drugs, within drug classes, or from one manufacturer to another and even based on prescriber’s creativity Eg: MPC, OMS, MTF, BE, EBB etc Use of Abbreviation Legibility Assessment is quite subjective and thus may be biased in the study Depends on the assessor’s familiarity with the handwriting of the prescriber

16 Decision Errors  Accounted for fewer of the prescribing errors than omission errors but more severe adverse effects were associated 18% (n=76) of the prescriptions was found at least one item was wrongly indicated Eg: Antibiotic indicated for viral fever. Wrong Indication

17 Inappropriate Dosing Decision Errors Antibiotic overdosing contributes the most. Greater risk to toxicity and antibiotic resistance due to inappropriate use.

18  Prescribing errors happened in almost all the patients regardless of their age, ethnicity and gender  Significant association between different disease stages and all the decision errors made was noted (P < 0.001) Wrong indication with skin disease and infectious disease; Inappropriate treatment duration and dosing frequency with UTI and endocrine diseases, respectively Wrong dosing happens more frequent with neonates Omission errors while dealing with cardiovascular, CNS and endocrine diseases. Results

19 Unauthorized prescribing  Malaysian Poisons and Sale of Drugs Act 1952 40% of the prescriptions with at least one item which should only be prescribed by registered medical practitioners.

20  determination of the severity of an error Severity of the prescribing errors detected could not be justified  data collection was based in Kampar district Not generalizable  no access to more detailed patient’s data Other prescribing errors might be undetected. Limitation

21  Prescribing errors are common and without appropriate safety processes such as pharmacist order review in place, present significant risk to patients.  From the study, the prescription errors made by medical assistants were pretty high, accounted for 97% regardless of patient’s age group, gender and ethnicity. But our study found that, the prescribing errors were not the same for different diseases being diagnosed. Around 40% of the prescriptions written by AMOs containing medications that are only authorized to be prescribed by registered medical officers only.  An improvement in health care provider knowledge is needed as practical step to minimize or avoid prescribing errors. Conclusion

22  It is believed that other districts and states within Malaysia especially health clinic at remote area facing this kind of problem where the AMOs are relied heavily on prescribing and assessing patient. larger scale study on evaluating medical assistant prescribing errors should be done in order to get a more generalizable data study to compare types as well as the frequency of prescribing error made by prescribers of other degree should be carried out to get a clearer picture on Malaysia prescribing errors epidemiology Suggestion for Further Study

23 References 1. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) – about medication errors. NCC MERP Web site. Available at Accessed Feb 12,2009. Accessed Feb 12,2009 2. S. Nadeem H. Shah, Mohamed Aslam, Avery AF. A survey of prescription errors in general practice. The Pharmaceutical Journal. 2001; 267: 860-4. 3. Franklin B Dean, Barber N, Schachter M, C Vincent. Causes of prescribing errors in hospital inpatients: A prospetive study. The Lancet. 2002; 359: 1373-8. 4. Dean B, Schachter M, C Vincent, Barber N. Prescribing errors in hospital inpatient: Their incidence and clinical significance. Qual Saf Health Care. 2002; 11: 340-4. 5. Franklin B Dean, Schachter M, Barber N. What is a prescribing errors. Qual Saf Health Care. 2002; 9: 232-7. 6. Khoo EM, Sararaks S, Lee WK, Liew SM, Azah AS, Rohana I, et al. (2008) Medical errors in MOH primary care clinics. A project under the letter of intent for improving patient safety. Kuala Lumpur Institute for Health Systems Research 2008. 7. Stubbs Jean, Haw Camilla, Taylor David. Prescription errors in psychiatry – a multi-centre study. Journal of Psychopharmacology. 2006; 20: 553-61. 8. Ridley SA, Booth SA, Thompson CM, The Intensive Care Society’s Working Group on Adverse Incidents. Prescription errors in UK critical care units. Anaesthesia. 2004; 59: 1193-200 9. Malaysian Poisons Regulations 1952. Regulation 23 (2). Available at Accessed Feb 7,2009. 10. Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for prevalence studies. Archives of Orofacial Sciences. 2006; 1: 9-14. 11. Bobb Anne, Gleason Kristine, Husch Marla, Feinglass Joe, Yarnold Paul R, Noskin Gary A. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med. 2004; 164: 785-92. 12. WHO Guide to good prescribing. World Health Organization. 13. Khaja KAJAI, Sequeira RP, Ai-Ansari TM, Damanhori AHH. Prescription writing skills of residents in a family practice residency programme in Bahrain. Postgraduate Medical Journal. 2008; 84: 198-204. 14. Minister of Health Malaysia Pharmaceutical Service Division. Amaran penggunaan ubat untuk rawatan “cough and cold” pada kanak-kanak. Pekeliling Pengurusan Farmasi Bil 1/2008. Available at Accessed Feb 2,2009 15. Avery Anthony J, Sheih Aziz, Hurwitz Brian, Smeaton Lesley, Chen Yen Fu Howard Rachel, et al. Safer medicines management in primary care. British Journal of General Practice. 2002;(Suppl):S17-S21.

24 References 16. Joint Formulary Committee. British national formulary. 56th ed. London: British Medical Association and Royal Pharmaceutical Society Of Great Britian; 2008. 17. Franklin B Dean. Leaning from prescribing errors. Qual Saf Health Care.2002; 11: 258-60. 18. Batty R Barber N. Ward pharmacy: a foundation for prescribing audit. Quality in Health Care.1992; 1: 5-9. 19. Meyer Tricia A. Improving the quality of the order – writing process for inpatient orders and outpatient prescriptions. Am J Health-Syst Pharm. 2000; 57; Suppl 4; S18 – S22. 20. Franklin B Dean. Leaning from prescribing errors. Qual Saf Health Care.2002; 11: 258-60. 21. Institute of Medicine. To Err is Human. Building a Safer Health System. Washington, DC: National Academy Press; 1999. 22. Institute of Medicine of National Academies. Preveting medication errors: the quality chasm series. Available at Accessed April 23,2009. 23. United State Pharmacopeia. Drug safety review. Medication error trends for 1999 – 2003. Available at Accessed April 23, 24. Expert Group on Safe Medication Practices. Creation of a better medication safety culture in Europe: Building up safe medication practices. Council of Europe 2006. 25. Barber N, Rawlins M, Franklin B Dean. Reducing prescribing error: competence, control and culture Qual Saf Health Care. 2003; 12: Suppl 1; i29 – i32. 26. Taylor LK, Kawasumi Yuko, Bartlett G, Tamblyn R. Inappropriate prescribing practices: The challenge and opportunity for patient safety. Healthcare Quarterly. 2005; 8: 81 – 5. 27. Zermansky AG. Who controls repeats. British Journal of General Practice. 1996; 46: 643 – 7. 28. Lesar TS. Prescribing errors involving medication dosage forms. Jorn Gen Intern Med. 2002; 17: 579-87. 29. Bergk V, Gasse C, Rothenbacher D, Leow M, Brenner H, Haefeli WE. Pharmacoepidemiology and drug utilization. Drug interactions in primary care: Impact of a new algorithm on risk determination. Clinical Pharmacology. 2004; 85 – 96. 30. Veehof LJG, Stewart RE, Haaijer-Ruskamp FM, Meyboom-de Jong B. The development of polypharmacy. A longitudinal study. Oxford University Press. 2000; 17 (No3): 261 – 7. 31. Ghaleb MA, Barber N, Franklin B Dean, Wong ICK. What constitutes a prescribing error in paediatrics. Qual Saf Health Care. 2005; 14: 352 – 7.

25 Dr. Mohamed Azmi Ahmad Hassali (Supervisor) Dr. Asrul Akmal Shafie (Co-Supervisor) Dr. Zuraidah Mohd. Yusoff (Co-ordinator) and all M. Pharm lecturers Dr. Junaidi B. Ibrahim (Peg. Kesihatan Daerah Kinta) Dr. Suraya Bt Amir Husin (Peg. Perubatan Pentadbir KK Kampar) Dr. Malek Sazali B Abdul Razak (Ketua Pengarah Hospital Kampar) My family, fellow friends, colleagues Acknowledgement


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