Prescription writing quality of psychotropic agents in MBBS interns in a private medical college hospital in Mangaluru

Background Rational prescription writing is an important skill to master during internship. This Quality Improvement (QI) project aimed to understand the state of prescription writing among interns posted in the Department of Psychiatry, analyze the causes responsible for errors in prescription writing and bring about a change in the current practice. Methods The MBBS interns are posted in the Department of Psychiatry for 15 days. During day 1 to day 5 of their posting, a pre intervention phase was conducted wherein prescriptions written by interns in the Department of Psychiatry were collected. The prescriptions were scored based on 14 criteria which were selected based on World Health Organization (WHO) guidelines and Medical Council of India (MCI) ideal prescription format. During PDSA (Plan Do Study Act) Cycle 1, an educational handout was distributed to the interns containing the MCI ideal prescription format and WHO guidelines regarding prescription writing. The brochure was also verbally explained to the interns. From day 7 to day 15 of their posting, prescriptions written by the interns were collected. The prescriptions were scored using the same criteria. Results During the pre intervention phase the mean total score of prescriptions was 9.54 ± 1.003. There was a significant improvement in the mean total score to 10.26 ± 0.746. There was a 7.54% improvement. There was also a significant improvement in several individual criteria. Conclusions The first PDSA cycle was successful in improving the quality of prescription writing among interns posted in the Department of Psychiatry. There is a need to implement more PDSA cycles to improve the quality still further.


Introduction
The problem of irrational drug prescription is prevalent worldwide. 1According to a World Health Organization (WHO) estimate, more than 50% of drugs are prescribed, dispensed, or sold inappropriately, and 50% of patients fail to take them correctly (https://www.who.int/activities/promoting-rational-use-of-medicines).
The prescription is the written instruction of the physician communicated to the patient.Writing rational prescriptions is an important skill for physicians.Poorly written prescriptions can negatively affect patient treatment, including worsening of the disease and making the prescriber liable to influence, which may lead to irrational prescribing. 2tional prescribing requires a logical approach that involves several key steps, including making the diagnosis, determining the therapeutic goals, consideration of treatment options, deciding the best treatment option, prescription and monitoring. 3 clinical practice, a doctor must be able to diagnose and immediately decide on the drug to be prescribed.Furthermore, patients may have different age, sex, and sociocultural features that affect the drugs prescribed.
Internship is a period of one year during which newly qualified Bachelor of Medicine and Bachelor of Surgery (MBBS) graduates practice under the guidance of senior doctors in designated hospitals.Studying the pattern of their prescriptions and suggesting changes is of utmost importance in improving the quality of patient care and enhancing the undergraduate medical education of interns.

Available knowledge
Most studies on the impact of medical errors, including prescription writing errors, have been conducted in developed countries.Medical errors are a leading cause of mortality in the United States.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 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 center 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

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 significant 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).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).

Aims
The aim of our QI project was to improve the quality of prescription writing among interns in the psychiatry department.
Our Specific, Measurable, Applicable, Realistic and Timely (SMART) aim was to improve the mean prescription scores.

Methods
Study setting: This study was conducted in the outpatient Department of Psychiatry, Kasturba Medical College Hospital, Attavar, Mangaluru.
Study design: Quality Improvement Project.
Study participants: MBBS interns in the Department of Psychiatry, Kasturba Medical College Hospital, Attavar, Mangaluru.

Sample size
The sample size for the study is 85 with 5% level of significance.
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 a) Criteria for assessing the quality of prescription: To determine the quality of prescription writing, we established certain criteria.These were based on WHO guidelines. 11The Medical Council of India (MCI) ideal prescription format was also used to create the criteria (https://delhimedicalcouncil.org/images/Latest-News/modalprescription.pdf).The prescriptions were evaluated using the following criteria: If the criteria are present, 1 point will be awarded, and if the criteria are absent, 0 points will be awarded.Then, the final score of that prescription was calculated by adding the points.The scores range from 0 to 14. Biological materials required -none

Data analysis
Statistical analysis was performed using IBM SPSS Statistics for Windows version 29 (IBM Corp., Armonk, N.Y., USA). 12The copyright license has been obtained by the institution.An open source alternative is Jamovi version 1.x. 13eans 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 AE 1.003.The mean scores across the various criteria were as follows (Table 1): 17

PDSA cycle 1 results
A total of 84 prescriptions were analyzed.The mean score of prescriptions written by the interns was 10.26AE0.746.The mean scores across the various criteria were as follows (Table 2): There was a significant improvement in the mean total score from 9.54AE1.003to 10.26AE0.746(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),sex 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).

Discussion
In this QI project, we attempted to ascertain methods to improve the quality of prescriptions written by interns posted in the Department of Psychiatry.
In the first PDSA cycle, we tried to fill in the knowledge gap with the help of a brochure and a verbal explanation of the format of prescription writing as prescribed by the MCI as well as the guidelines stipulated by the WHO.
After PDSA cycle 1, we found a significant improvement in the total scores of the prescriptions as well as a significant improvement across several criteria, including date, gender of patient, generic name of the drug, drug name in capital letters, dosage form, and total quantity of drugs to be given by the pharmacy.
The aim of this QI project was to improve prescription writing scores.After the first cycle, a 7.54% improvement was observed.
A study conducted in The Oxford Dental College and Hospital, Bangalore, found that the patient's name (95.6%), age (91.2%), and gender (91.6%) were written by the majority of the students.The patients' outpatient number (0%), address (0%), and contact number (0.4%) were missing in almost all prescriptions, which is in agreement with our study where the name, age, and gender were mentioned in 100% of the prescriptions collected. 9rthermore, a study was conducted regarding the impact of patient-based teaching in improving the prescription writing skills of II MBBS students.This study showed that patient-based teaching improves responsibility, focus, and memory. 14 our study, our informal teaching session at the end of PDSA cycle 1 revealed a similar improvement, which may be attributed to the orientation given.
In another study carried out at Nobel Medical Teaching Hospital, Biratnagar, Nepal, there was a 0% error in the patient's name, age, and sex, which was similar to our findings. 15wever, the findings of other studies are different from ours.In a study conducted at Oxford Dental College and Hospital, Bangalore, it was found that the parameters that were lacking the most were dosage instructions, strength of the drugs, and duration of the drugs, which was not the case in our study. 9According to our study, the total quantity of drugs to be given by the pharmacist, dosage form, and generic names were not mentioned.
The lack of generic names written in our study could be because interns have very little time to write prescriptions or because psychiatric medications are not as common as analgesics or gastritis medicines; hence, additional work and reading is required to become aware of them, and either the interns did not have an incentive to learn this or did not have enough time to cover this aspect of prescription writing.
In our study, the criteria for which there was no significant improvement were criteria that already had high scores in the pre intervention phase.
Furthermore, another study in Patna, where prescriptions from different OPDs in different departments were audited, showed that only 10% of the prescriptions contained drugs prescribed in their generic name.Frequency, route, and duration of drug administration were mentioned in 86.7%, 79.3%, and 69.6% of the prescriptions, respectively.Among the prescriptions, 42.5% were easily legible.Hence, it was not in accordance with the WHO standards. 16gibility was not a criterion for this study.If we had to look at it subjectively, none of the prescriptions were difficult to read by the people undertaking the study, thus giving us a higher score in that field than in the study mentioned above.
An important criterion that was judged in the study conducted in Nobel Medical Teaching Hospital, Biratnagar, were 2 same drugs or the same category mentioned in the same prescription, which accounted for 0.5% of their total errors. 15his category was not judged in our study because it was not a criterion mentioned in the MCI ideal prescription and it is an indicator of skills and not methodology, which was what our study mostly focused on.

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.

Conclusion
This Quality Improvement project enabled us to understand that brochures regarding prescription writing and verbal explanations are useful tools for improving the quality of prescriptions written by interns in the department of psychiatry.Therefore, there is a need to find more innovative methods to improve the quality of prescriptions.There is a need to improve interns' training by emphasizing rational prescription writing during internships.Further studies are required to determine whether this method is universally applicable.

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.

Data availability
Open Science Framework: Prescription writing quality of psychotropic agents in MBBS interns at a private medical college hospital in Mangaluru.https://doi.org/10.17605/OSF.IO/HZGFC. 17is project contains the following data: • Intern prescription writing scores xlsx (scores of prescriptions written by interns during the preintervention phase and PDSA Cycle 1).
• Intern Consent Form.docx • Patient Consent Form.docx • Checklist for Prescription writing quality of psychotropic agents in MBBS interns in a private medical college hospital in Mangaluru.docx

Reporting guidelines
This study was based on the SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines. 18ta are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Sanjeev Badiger
A J Institute of Medical Sciences and Research Centre, Mangaluru, India The topic selected by the author is relevant to the present scenario , as prescription is considered as an important Document.This article highlights the need for quality prescription writing and the need for improvement in prescription writing .Studying the pattern of their prescriptions and suggesting changes is of utmost importance in improving the quality of patient care and enhancing the undergraduate medical education of interns. Major

Vandana Gaur
Department of Psychology, SDM Government PG College in Doiwala, Dehradun, Uttarakhand, India The introduction provides a clear rationale for the study, emphasizing the importance of accurate prescription writing in clinical practice, particularly for psychotropic agents, which are associated with complex dosing and potential side effects.The study's objectives are well-defined, focusing on evaluating the prescription writing quality of psychotropic agents among MBBS interns.The results section (assuming it is well-presented) likely provides valuable insights into the quality of prescription writing among interns.It is essential that this section includes data on common errors and areas where interns perform well, as this information could inform future training programs.The discussion should ideally interpret the results in the context of existing literature, highlighting both strengths and weaknesses in the prescription writing practices of the interns.It should discuss the implications for patient safety and medical education.
The study addresses an important issue in medical education and patient safety.The focus on psychotropic agents is particularly relevant, given the complexities involved in prescribing these medications.The methodology appears sound, and the study has the potential to provide valuable insights.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes Are sufficient details of methods and analysis provided to allow replication by others?Yes

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Human Psychology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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Figure 1 .
Figure 1.Process map regarding the process by which interns write prescriptions.

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

1 . Date 2 .
Name of patient 3. Age of patient 4. Contact number of the patient 5. Gender of the patient 6. Generic name of the drug 7. Drug name in capital letter 8. Strength 9. Dosage form 10. Route of Administration 11.Total quantity of drugs to be given by pharmacy 12. Number of days to take the drug 13.Number of times to take the drug in a day 14.Signature or initials of the prescriber b) Educational handout: This was based on the WHO Practical Manual Guide to Good Prescribing. 11

Table 1 .
Mean scores of participants in pre intervention phase.

Table 2 .
Mean scores of participants in PDSA Cycle 1.

Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.Reviewer Expertise: Deaddiction psychiatry, Consultation-liaison Psychiatry, Mood Disorders.I confirm that I

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
Reviewer Report 16 August 2024 https://doi.org/10.5256/f1000research.158550.r313887© 2024 Gaur V.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.