MEDICATION PRESCRIBING ERRORS IN PAEDIATRIC OUTPATIENTS PRESCRIPTIONS AT A PAEDIATRIC HOSPITAL IN NEPAL

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1 WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Sunil et al. SJIF Impact Factor Volume 6, Issue 1, Research Article ISSN MEDICATION PRESCRIBING ERRORS IN PAEDIATRIC OUTPATIENTS PRESCRIPTIONS AT A PAEDIATRIC HOSPITAL IN NEPAL Dr. Sunil Shrestha 1 * Dr. Prayash Ghimire 2, Dr. Laxman Wagle 3 and Renu Shrestha 4 1 Research Scholar, Pharm.D (Post Bacc) Department of Pharmacy, Kathmandu University, Kavre, Nepal. 2 Lecturer, Pharm.D (Post Bacc), Department of Pharmacy, CIST College, New Baneshwor Nepal. 3 Research Scholar, Pharm.D (Post Bacc), Department of Pharmacy Practice, Sri Adichunchanagiri College of Pharmacy, BG Nagara , Mandya District, Krnataka, India. 4 HOD, Associate Professor, Department of Pharmacy, Asian College for Advance Studies, Satdobato, Nepal. Article Received on 08 Nov. 2016, Revised on 28 Nov. 2016, Accepted on 18 Dec DOI: /wjpps *Corresponding Author Dr. Sunil Shrestha Research Scholar, Pharm.D (Post Bacc) Department of Pharmacy, Kathmandu University, Kavre, Nepal. ABSTRACTS Medication errors are potential errors and can be prevented. Identification of these errors can help to reduce further injuries. The study was conducted with objective to determine the prevalence and nature of medication errors in pediatric out-patients and also to study their prescribing pattern. Methods: A cross-sectional descriptive study was conducted in International Friendship Children Hospital, Maharajgunj, Nepal for a period of 3 weeks during which 205 outpatient prescriptions were studied for medication error after taking patient consent. Data were collected in data collection form through prescription for prescription error. Data were analyzed using SPSS. Results: Among 205 prescriptions, 117 (57.1%) were males and 88 (42.9%) were females where they were prescribed with 3.35 number of average drugs. We found 165 prescribing medication errors among 688 drugs prescribed. The prevalence of omission of drug duration was the highest (36.96%), followed by unintentional prescription of drug (32.12%), frequency missing (6.66%) and overdose error (9.70%). The other types of errors observed were under-dose (4.85%), no indication (2.43%), and incorrect frequency Vol 6, Issue 1,

2 (2.43%), omission of dose/strength (1.82%) and omission of patient s weight (1.21%). The major diseases diagnosed during the study were acute respiratory infection (48.1%) and the major drugs prescribed were antibiotics, antihistamines, anti-inflammatory and expectorants. KEYWORDS: paediatric prescribing pattern, medication prescribing error. INTRODUCTION Medication error is a common cause of morbidity and mortality in a variety of health care settings [1,2] The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as any preventable error that may cause or lead to inappropriate medication use or patient harm while medication is in control of the health care professional, patient or consumer. Medication error can occur at any stage of medication use process like prescribing, transcribing, dispensing, administration and monitoring. [3] Prescribing error as a most common type of error (20-40%) had been documented in countries like Thailand, Georgia and Colorado. [4,5] Prescription error is a failure in the prescription writing process leading to wrong instruction about identity of the recipient, the identity of the drug, the formulation, dose, route, timing, frequency and duration of administration. [6] Every day a high missing legal or procedural requirements has been observed in teaching hospitals with prescription errors such as duplication, wrong strength, wrong dosage form, wrong route and drug-drug interactions [7-9] which end up with several drug related problems such as over-dosage, under-dosage, drug interactions, drug allergy and non-compliance [10] Children are recognized to as high risk population for medication errors and adverse drug events due to multiple of reasons. The risk is estimated to be three times higher in admitted children than in admitted adults [11-12] There are fewer studies conducted to observe prescription error at paediatric unit in Nepal. One study by Ramesh Sharma Poudel and coauthors from Nepal found 4.7% of prescription error rate at paediatric outpatient department of teaching hospital. [13] Having a better understanding of the types of error in a paediatric hospital would be an important step toward quality improvement in children drug therapy. Thinking these things in mind we conducted a study with following objectives. To study prescribing pattern of paediatric OPD prescriptions. To study the medication prescription errors in paediatric outpatients prescription at paediatric hospital. Vol 6, Issue 1,

3 METHODS Study Type: Prospective cross-sectional study. Selection of Study Area: Pediatric patients visiting the OPD of International Friendship Children s Hospital (IFCH), Maharajgunj between 13 th January 2012 and 26 th January 2012 were selected for the study. Study Population: This study included all of the medication orders that were prescribed in the general pediatric OPD ward, for children up to 14 years of age during the designated study period. Inclusion Criteria The prescription with 3 or more drugs were only included in this study. Exclusion Criteria Prescription with complementary and alternative medicine (CAM) were excluded. Sample Size The sample size was two hundred twenty five (N= 205) medication orders that were prescribed in the general pediatric OPD ward. Data Collection Tools Prescription This study included all of the medication orders that were prescribed in the general pediatric OPD ward. Study Variables Independent variables Prescription parameters 1. Patient s name 2. Age 3. Weight 4. Sex 5. Drug name 6. Frequency of dosing Vol 6, Issue 1,

4 7. Duration of dosing Dependent variables Types of medication errors. Omission Errors Omission of dose Omission of frequency Omission of indication Omission of patient s weight Omission of duration of drug use Dose Errors Overdose Under dose Frequency Errors High frequency Low frequency Other Errors Data Analysis The data were entered in MS-Excel 2007 and transferred to SPSS 16. Tables and figures were generated using Microsoft excel. BNF for children 2009 was used for the reference to document the errors if needed. RESULT AND DISCUSSION Table 1: Gender Distribution Gender Frequency(N) Percentage (%) Male % Female % Total % This showed that males (57.1%) outnumbered the females ( 42.9%) in our study population. Vol 6, Issue 1,

5 Figure 1: Distribution of patients according to the age group We observed maximum number of patient (38.05%) were in between the age categories of 1-3 years (38.05%) followed by 0-1 years (21.46%),3-5 years(14.63%),7-10 years(9.26%), 5-7 years(8.3%), years(4.4%) and years( 3.9%) respectively. Figure 2: Diagnosis detail of studied population The major diagnosis observed during the study was acute respiratory infection (48.10%) followed by acute gastroenteritis (14.40%) and others as shown. The minimum diagnosed case was Sinusitis (1.40%) % of the diagnosed cases contained the diseases states like soft tissue injury, cellulites, otitis media, cut injury, urinary tract infection, dysentery etc. Vol 6, Issue 1,

6 Figure 3: Prescribing pattern of drugs Major drug prescribed for the pediatric patients were antibiotics i.e. 25.4% (N=688) followed by anti-inflammatory drugs (24%) and others as shown. The minimum drug prescribed were antivirals (0.80%). The other drugs prescribed were antiemetics, antispasmodics, decongestants, antiamoebics, digestive enzymes etc. Among the antibiotics prescribed 85.48% were Augmentin (Amoxicillin + Clavulanic acid). The other antibiotics used were Cefixime, Cefpodoxime, Cefalexin, Cloxacillin, Ampicillin, Amoxicillin etc. Table 2: Types of prescribing medication errors. Types of errors Frequency of errors Percentage (%) A) Omission Errors Omission of dose Omission of frequency Omission of indication Omission of patient s weight Omission of duration of drug use Subtotal * B) Dose Errors Overdose Under dose Subtotal * C) Frequency Errors High frequency Low frequency Subtotal * D) Other Errors Misspelling of drug s name Unintentional prescription of drugs Subtotal * TOTAL Vol 6, Issue 1,

7 We observed 49.1% of omission errors followed by 14.54% of dose errors, other errors (33.94%) and frequency errors 2.42%. respectively. Figure 5. Errors based on the dosage forms of drugs We observed 65.8% of medication error were associated with syrup formulation followed by tablet (11.7%), nasal drop/spray (9.2%), mouth paint (5%), eye/ear drop (4.2%), cream/lotion (4.2%). Figure 6: Prevalence (%) of medication errors in different medication categories We observed high number of medication error in medication categories like antihistaminics (16.36%) followed by antibiotics(16.36%), nasal drops/spray(10.91%), antiemetics(10%), antacids(4.54%), expectorants(4.54%), anti-inflammatory(4.54%), vitamin B complex (1.82%), paracetamol(1.82%), antiviral (0.91%) etc.28.2% of medication errors were not associated with drugs. Vol 6, Issue 1,

8 DISCUSSION A medication error is an episode associated with use of medication that should be preventable through effective control system. We studied prescribing error in 205 subjects where males and age group between 1-3 years were more as well as acute respiratory tract infection as a common diagnosis. The numbers of drugs prescribed per patient were between 1 and 6 with a mean value of 3.35 drugs per prescription. While four drugs prescription were the commonest, one drug per prescription was the least. Only 99 out of 205 prescriptions were completely free of error giving an error rate of 80.48%. This shows that pharmacist can identify errors which can be subsequently prevented. However, pharmacists were not able to intervene in all the detected errors as few prescribers were reluctant to accept their error and make correction. We observed mostly omission type of prescribing error followed by dose errors and others. Regarding the omission errors two (1.24%) prescriptions did not have the weight of the patients. The prevalence of omission of duration of use was on antihistamines, expectorant, anti-inflammatory and antibiotics. Similarly, the prevalence of omissions of dose/strength, frequency and indication were found to be 3 (1.46%), 11 (6.83%) and 4 (2.48%) respectively. When such omission occurs there is a chance of injuries related to incomplete drug information. Regarding the dose errors we classified inappropriate dose of drugs could be in the form of under-dose or over-dose. Some studies also demonstrated incorrect dose as a most common type of prescribing error [8], in contrast of our study. Dose error constituted of 14.54% of the total errors with overdose as the main type of dose error (66.66%). In general, dosing errors are the most common type of medication error in children, with overdoses generally outnumbering under-doses were also found by number of studies. [9,12,14] The prevalence of over-dose was found in antibiotics (43.75%), anti-inflammatory (12.5%) and antihistaminics (6.25%). Similarly, under-dose was observed in antibiotics (50%) and antihistamine (12.5%). Dose and frequency error may cause inadequate or excess plasma concentration leading to inadequate therapeutic effect or toxicity. Of the total errors, 3 cases (1.86%) contained misspelling of the drug s name. 53 cases (32.92%) contained unintentional prescription of drugs. Here, the unintentional prescription means the prescription of drugs which were given for the purpose without indicating it in the diagnosis or in any part of the prescription. For e.g. for a patient suffering from acute gastroenteritis, chloramphenicol eye drop was also used without indicating the cause of Vol 6, Issue 1,

9 prescribing it in the prescription. Similarly, a case of allergic dermatitis was found to be prescribed with expectorant and Liv-52, the cause of prescription of these drugs not being indicated in the prescription. These type of errors has to be prevented. Increased workload, working environment, level of awareness of patients, poor physician-patient counseling, lack of involvement of pharmacist in treatment plan, and inadequate supervision and monitoring may account for these errors in our context. Most common dosage forms that were prone to prescribing error were syrup and tablets followed by others. In all type of dosage forms errors happened at least one time. We witnessed the fact that antihistaminics and antibiotics were the most common class of medicines to occur prescribing error. Prescribing pattern of drugs showed that among 688 drugs that were prescribed, 18% were antibiotics. Among these antibiotics, Amoxicillin + Clavulanic acid were used in maximum amount (85.48%). The other commonly prescribed drugs were anti-inflammatory, expectorants, antihistamines, albendazole, paracetamol etc. CONCLUSION Prescription error was common in outpatient settings. Our study highlights that prescribers and pharmacists in Nepal need to work collectively in patient care. There is need of national level drug policy on matters related to prescribing error. REFERENCES 1. Brennan TA. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study. Engl J Med, 1991; 324: Bates DW. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. JAMA, 1995; 274: Gandhi TK, Weingart SN, Seger AC, Borus J, Poon EG. Outpatient prescribing errors and the impact of computerized prescribing. J. Gen. Intern. 2005; 20: Barker KN, Flynn EA, Pepper GA, Bates DW. Medication errors observed in 36 health care facilities. Arch. Intern. Med, 2002; 162: Sangtawesin V, Kanjanapattanakul W, Srisan P, Nawasiri W, Ingchareonsunthorn P. Medication errors at Queen Sirikit National Institute of Child Health. J. Med. Assoc. Thai, 2003; 86: Aronson JK. Medication errors: definitions and classification. Br J Clin Pharmacol, 2009; 67(6): Vol 6, Issue 1,

10 7. Ni KM. Noncompliance with prescription writing requirements and prescribing errors in an outpatient department. Malaysian Journal of Pharmacy, 2002; 1(2): Folli HL. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics, 1987; 79(5): Lesar TS et al. Medication-prescribing errors in a teaching hospital: A 9-year experience. Arch Intern Med, 1997; 157: Díaz GE et al. Analysis of pharmaceutical intervention in outpatients pharmacy department. Farm Hosp, 2013; 37(4): Preventing pediatric medication errors. Sentinel Event Alert. Oakbrook Terrace, Ill: The Joint Commission; Kaushal R, Bates DW, Landrigan C. Medication errors and adverse drug events in pediatric inpatients. JAMA, 2001; 285: Ramesh Sharma Poudel, Shakti Shrestha, Dipendra Khatiwada, Santosh Thapa, Aastha Prajapati, Lekhjung Thapa, Rojina Baral, Prescription errors and pharmacist s intervention at outpatient pharmacies of two teaching hospitals of central Nepal World J Pharm Sci., 2015; 3(3): Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, Goldmann DA, Bates DW: Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatient. Pediatrics, 2003; 111(4): Vol 6, Issue 1,