Presentation on theme: "EVALUATION OF PRESCRIBING PRACTICES BY MEDICAL ASSISTANTS OFFICERS AT MALAYSIAN PUBLIC HEALTHCARE FACILITY Yee Siew Mei School Of Pharmacy, Division of."— Presentation transcript:
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 SiewMei.Yee@taylors.edu.my Co-Author Dr. Mohamed Azmi Ahmad Hassali Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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
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
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
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
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
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
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
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
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
Decision Errors (n=386) Type of ErrorsFrequency Drug Interaction81 Polypharmacy81 Wrong Indication76 Inappropriate Dosing Frequency60 Inappropriate Duration of Treatment47 Inappropriate Dosing39 Contraindication2
Top 5 prescribed drugs with the highest number of errors
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
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
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
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
Inappropriate Dosing Decision Errors Antibiotic overdosing contributes the most. Greater risk to toxicity and antibiotic resistance due to inappropriate use.
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
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.
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
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
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
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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