Prescriptions written by MBBS Interns in the Department of Psychiatry in a Medical College Hospital in Mangaluru: A Quality Improvement Study

Available knowledge

Studies conducted in Asian countries have reported varying rates of errors when writing prescriptions. These values range from 7% to 35.4%.⁴

A study conducted in Bangladesh found that 78% of drugs were prescribed by their generic names, 85% complied with the essential drug list, and 81% were dispensed according to prescription.⁵

In a study conducted in private hospitals in western India, prescriptions were analyzed according to WHO prescribing indicators. It was found that out of the 250 prescriptions analyzed, patient details were not written in 100% of prescriptions. Drug dosage, instructions regarding drug administration, and the duration of the treatment were not completely written in 90%, 74%, and 80% of prescriptions studied, respectively. The prescriber’s medical registration number was not mentioned in any of the prescriptions.⁶

In a study carried out in the non-governmental organization sector in West Bengal, India, it was found that the majority were signed, legible, and complete with respect to age/gender data, 95.5% used Latin abbreviations, and 7.7% mentioned neither signs, symptoms, nor diagnosis. Irrational fixed-dose combinations were used in 45.6% of the prescribed drugs. Only 45.7% of prescribed drugs conformed to the WHO model list of essential drugs.⁷

In a study of selected rural pharmacies in southern India, it was found that 91.4% of prescriptions did not contain any drug prescribed by its generic name.⁸

In a study in The Oxford Dental College and Hospital, Bangalore, prescriptions were analyzed for several features, such as patient details, doctor’s information, and drug information. Prescriptions written by undergraduate students were better than those written by interns and postgraduates (PGs).⁹

The prescriptions written by interns were studied in a primary health centre in India, and it was found that 34.97% of drugs were prescribed by generic name and 58.7% of drugs prescribed were from the essential drug list of India.¹⁰

A study conducted in India sought to understand the factors involved in the problem of irrational prescriptions. The prevalence of Fixed Drug Combinations in India was found to be one such factor.¹¹

Another study showed that interventions positively impact the ability of medical students to write prescriptions, however the type of intervention which is best suited for this purpose is still not agreed upon.¹²

Rationale

After studying the literature available regarding the state of prescription writing, this Quality Improvement (QI) project was conceptualized. This QI project sought to understand and bring about improvements in the quality of prescriptions written by interns posted in the Department of Psychiatry.

A process map was created that outlined the process through which the interns were posted in the Department of Psychiatry to write prescriptions ( Figure 1).

Figure 1. Process map regarding the process by which interns write prescriptions.

We carefully studied the process and brainstormed possible causes of the poor quality of prescription writing among interns with the help of a fishbone diagram ( Figure 2).

Figure 2. Fishbone diagram regarding causes of poor prescription writing.

Aims

The aim of our QI project was to improve the quality of prescription writing among interns posted in the Psychiatry department.

Our Specific, Measurable, Applicable, Realistic and Timely (SMART) aim was to improve the mean prescription scores.

Inclusion criteria

Exclusion criteria

Study duration: 1 year from November 2022 till August 2023

Sample size

The sample size for the study is 85 with 5% level of significance.

Z = 1.96 is standard normal value at 5% level of significance

Ρ = Proportion = 67%

d = Absolute Precision = 10%

Sampling method: Convenient sampling method.

Methodology: As a part of compulsory rotation during internship, the interns are posted in the Psychiatry department for 15 days. We used the Plan-Do-Study-Act (PDSA) model to conduct this Quality Improvement Project. The PDSA model is a four-step model used to improve the process or bring about a change in a system. We divided our study into two phases. The pre intervention phase and PDSA cycle 1 were repeated for each batch of interns who participated in this study.

The PDSA model used for this study consisted of the following:

Plan: Based on the results of the pre intervention phase, we planned to implement the intervention.

Do: We implemented the intervention

Study: We studied the result of the intervention

Act: Using an educational handout on prescription writing during internship

Pre intervention phase

On the first day of the psychiatry postings, the interns were informed about the study and written informed consent was obtained from them. They were instructed to create copies of the prescriptions that they wrote with the help of a carbon sheet which was provided with the empty prescriptions. Informed written consent was obtained from the patients whose prescriptions were used in the audit.

For the first 5 days of Psychiatry posting, carbon copy of the prescriptions were collected before giving the original prescription to the patients.

PDSA cycle 1

On day 6 of the posting, the interns were given an educational handout which was based on the WHO practical manual guide to good prescribing that explained the format of the prescriptions to be followed. The investigators also explained regarding the format of the prescription writing to be followed by the interns.

On days 7–15, the interns again created copies of the prescriptions they were writing with the help of carbon sheets provided with the empty prescriptions, and these were collected before giving the original prescription to the patients.

Tool for data collection

Biological materials required - none

Data analysis

Statistical analysis was performed using IBM SPSS Statistics for Windows version 29 (IBM Corp., Armonk, N.Y., USA).¹⁴ The copyright license has been obtained by the institution. An open source alternative is Jamovi version 1.x.¹⁵ Means and standard deviations were calculated. The t-test was used for continuous variables, and the chi-square test was used for categorical variables. Statistical significance was set at p value<0.05.

Pre-registered data analysis

The data analysis in this study was not pre-registered.

Pre intervention phase results

In total, 91 prescriptions were analyzed. The mean score of prescriptions written by the interns was 9.54±1.003. The mean scores across the various criteria were as follows ( Table 1):¹⁶

PDSA cycle 1 results

A total of 84 prescriptions were analyzed. The mean score of prescriptions written by the interns was 10.26±0.746. The mean scores across the various criteria were as follows ( Table 1):

There was a significant improvement in the mean total score from 9.54±1.003 to 10.26±0.746 (p<0.01). There was an improvement of 7.54% after PDSA cycle 1.

There was also a significant improvement in the following criteria: date (p<0.01), gender of patient (p=0.13), generic name of the drug (p=0.01), drug name in capital letters (p=0.045), dosage form (p=0.07), and total quantity of drugs to be administered by the pharmacy (p<0.01).

There was no significant improvement in the Age of Patient (p=0.083), strength (p=0.336), route of administration (p=0.159), number of days to take the drugs (p=0.897), number of times to take the drug in a day (p=0.174), or signature or initials of the prescriber (p=0.196).

Limitations

Instructing interns to make copies of their prescriptions may have led them to pay closer attention to their prescription writing, leading to a biased result. To further understand the factors affecting the prescriptions written by interns, a qualitative component like Focussed Group Discussion would add valuable insights.

Ethics and consent

The protocol was approved by the Institutional Ethics Committee Kasturba Medical College, Mangalore (Reg. No. ECR/541/Inst/KA/2014/RR-20) before commencement of the Quality Improvement Project and Ethical Approval was obtained. The protocol number of the study was IECKMCMLR-10/2022/423. The date of approval was 19/10/2022. Written informed consent for the study was obtained from the interns and the patients/relatives of the patients, respectively. Participants had the right to withdraw from the study at any time.