Prescription

Prescription

Definition, Parts of prescription, Handling of Prescription and Error of Prescription

Author: Alok Bains

Word prescription is derived from two words “pre” means “before” and “script” means “written”. It is a written document by the medical practitioner before administration of the medicines.

“Prescription is a written or electronically generated order by a registered medical practitioner to a pharmacist to compound and dispense specific medicine for the patient”.

Parts of prescription

A complete prescription consists of following parts.

1. Name and address of hospital/clinic

2. Medical practitioner information: It includes name and sir name, designation, qualification, registration number, and contact number of the medical practitioner, Name and address, email address of the hospital/clinic. All these are required to contact hospital or medical practitioner in emergency, clarification regarding missing words, confirmation about medication and instruction etc.

3. Date of prescription: Date must be written on the prescription by medical practitioner. It is written just before prescribing medicines. It helps to track the validity of the prescription. Date on prescription is helpful for the pharmacist to know gap between prescription written and medicine dispensing. Medication should be dispensed within reasonable time. Pharmacist shall question, if prescription is brought after two or three days gap Narcotic and habit forming drugs should not be dispensed after gap of ten days. Date on prescription also helps pharmacist at the time of prescription refilling.

4. Patient information: It includes full name, age, sex and address of the patient. If these all are not written then pharmacist shall ask all these details from the patient and write on the top of prescription. Full name helps pharmacist to distinguish patient of similar name. Further patients are distinguished with the help of age and sex of the patient. Age and sex also help pharmacist to calculate and verify dose of the prescribed medicines. Address of the patient helps pharmacist for any reference in the latter stage. It also helps pharmacist to deliver medicines personally in an emergency or any other situation.

5. Superscription: Symbol “Rx” represents the superscription part of the prescription. It is written just beginning of the prescription that is medication order. In mythology, symbol Rx was a prayer to Jupiter to quick cure of the patient. Jupiter is a God of healing in Roman civilization. Actually symbol Rx was Rj. In latter stage symbol “Rj” was changed to “Rx”. Now this symbol is considered as “take thou” or “you take”. It is also considered as abbreviation of word “Recipe”.

6. Inscription: It is body of prescription and considered as main part of the prescription. It contains name of the medicine, dosage form and quantity of medicines/ingredients to be dispensed. The name of each medicines/ingredients is written in separate line followed by the quantity.

   Complex prescription contains name of various ingredients. These ingredients are divided into three groups: Active pharmaceutical ingredients (API) to produce therapeutic effect, excipients to enhance medicament action and their acceptability among patient, and last is name of diluent/vehicle to increase volume or bulk. Complex prescription is written to compound dosage form by the pharmacist inside pharmacy. But now a day, it is not in practice. Pharmacist dispenses already prepared dosage form. Thus now a day inscription part contains only name of medicines, its dosage form and quantity to be dispensed.

   In practice, Medical practitioner writes dosage form followed by name of medicine and quantity. For example “Tab. Paracetamol 500 mg”. Medical practitioner can write either brand name or trade name of the medicine, Quantity unit shall be in metric system.

7. Subscription: It is medical practitioner's direction to the pharmacist regarding dosage form, number of dose to be dispensed, how to take medicines and any other additional information. Now a Day this part of prescription is missing or less frequently used. It is because medicines are not compounded in the pharmacy.

8. Signatura/Signa: It is direction to the patient. It indicates route of administration of the drug, time of drug administration, manner of administration, medicine quantity, number of dose or unit of dose to be taken, etc. These instructions must also be written on the label of medicines by the pharmacist.

9. Signature, Address and registration number of the Medical practitioner: Prescription may be hand written or typed. It must be signed by the medical practitioner with name and registration number of the medical practitioner. Signature makes prescription legally valid document.

   Author: Alok Bains

Handling of Prescription

Handling prescriptions in a pharmacy is a critical process. There are several steps to ensure patient safety and proper medication dispensing. The following steps are followed to handle the prescription.

1. Receiving: The Pharmacist shall receive the prescription from the patient/caregiver. Unauthorized persons shall not be allowed to receive or read prescriptions inside the pharmacy. Patients must feel comfortable and friendly with the pharmacist. Communication should encourage the patient to ask any doubt from the pharmacist.

2. Reading and checking: The pharmacist shall read and check the prescription to identify the patient, understand the prescription, and estimate the time to dispense prescribed medicines. If the patient's name, age, sex, and address are not written on the prescription, then the pharmacist shall write all these on top of the prescription. Pharmacists shall inform the patient/caregiver of the time required to dispense medicines.

   Pharmacists shall carefully examine the prescription behind the counter about ingredients, medicines, dose, interactions, counter-indications, double medication, directions, any errors, etc. Patients should not come to know about errors in the prescription. This disclosure may shake patient faith in medical practitioners. This will affect treatment psychologically.

   Pharmacists shall read and understand the prescription completely before compounding and dispensing. Pharmacists shall not use guesses about abbreviation words illegible words or confusing words. It may lead to serious consequences. There are several drugs with similarities in their names and pronunciation. For example quinine and quinidine, prednisone and prednisolone, etc. If there is any error or doubt, the pharmacist shall consult a fellow pharmacist or medical practitioner to rectify errors or to clarify doubts.

3. Collection and weighing: The pharmacist shall collect the medications on the left-hand side of the counter. All these shall be arranged to avoid their mixing. After proper verification, materials shall be shifted to the right-hand side of the counter. This assures correctness by a physical check. Label of the each container shall be read at least three times. First during their collection from the shelf of pharmacy, second during shifting from the left-hand side to the right-hand side on the counter, and while returning the balance medicines to their proper place in the pharmacy.

4. Compounding: This is the most crucial phase of prescription handling. Now a day it is not in practice. But this step is followed during the dispensing of medicines. There shall be accuracy and cleanliness for proper technique to handle medicines in the pharmacy. Only one prescription shall be handled by the pharmacist at one time. Handling two or more prescriptions at one time, diverting attention to his colleagues, attending phone calls, engaging in any other work, etc. may lead to the wrong dispensing of medicines and mistakes in dose calculation. This will have serious consequences.

5. Finishing: The pharmacist shall deliver medicines in suitable containers. This depends upon the quantity of medicines and types of dosage forms to be dispensed. Pharmacists label the filled container using good-quality paper and adhesive. The size of the label shall be suitable for the size of the container. Normally the following information is mentioned on the label: Name of medicine, Name, age, and sex of patient, Direction to use medicine, Dispensing date, expiry date, storage condition, name and address of pharmacy, and registration number of pharmacist. After proper labeling, the pharmacist shall thoroughly examine the medicine put his signature on the prescription, and dispense the medicine.

   Alok Bains

Errors in prescription

Prescription errors lead to medication errors. Prescription errors are mainly due to abbreviation, dosage form, dose, instructions to patient, and incompatibility. Errors in prescription will have serious consequences. Thus, healthcare providers must minimize the errors in the prescription. Errors in prescription occur at various stages, The following are the sources of errors in the prescription:

1. Prescribing errors: Medical practitioners write prescriptions. The prescribing errors may be due to abbreviations, wrong medication, wrong dose, incomplete information, etc.

   Abbreviation: Most medical practitioners use abbreviations words in prescriptions. This causes errors in dispensing due to the wrong interpretation of abbreviated words by the pharmacists. Medical practitioners should use well-accepted abbreviated words to avoid this error.

   Name of the drug: There are several drugs that sound similar but they are different drugs. Pharmacists may dispense the wrong medicines to patients. This is mainly due to the bad handwriting of medical practitioners. Pharmacists must ensure clarity and understanding of the drug name before compounding and dispensing medicines.

   Strength of medicines (Dose): The dose of medicines varies with the line of treatment. Medical practitioners may miss writing doses of medicines. Pharmacists must verify the dose of medicines from medical practitioners before compounding and dispensing. For example, paracetamol tablet is available in the market as paracetamol tablet 500 mg and paracetamol tablet 650 mg.

   Sometimes medical practitioners write high doses or low doses of the drug. Pharmacist's opinions do not match with the medical practitioner then the pharmacist must consult the medical practitioner before compounding and dispensing medicines.

   Sometimes medical practitioners prescribe sustained dosage forms with directions to take them three times a day or four times a day. Sustained release dosage forms are designed to release drugs slowly. Prescribing it three times of day or more causes an overdose of the drug. Pharmacists must consult medical practitioners before dispensing sustained-release drugs with inappropriate frequency of drug administration.

   Incompatibility: Pharmacists must check incompatibility in the prescription. If two or more medicines are prescribed they may interact to produce harm to the patient. Some drugs may also interact with food. The pharmacist must advise the patient about it. E.g., Tetracycline should not be taken with milk

2. Dosage form of drug: Medicines are available in different dosage forms. Medical practitioners may prescribe medicines without mentioning the dosage form of medicines. Each dosage has formed its own advantages and disadvantages and sometimes changes in its therapeutic effect. Pharmacists must consult medical practitioners if the dosage form is not mentioned in the prescription or if the wrong dosage form is mentioned by the medical practitioner.

3. Transcription errors: Transcription errors are mainly due to illegible handwriting of medical practitioners or communication errors if prescription details are verbally communicated.

4. Dispensing error: Pharmacists or pharmacy staff may dispense the wrong medicine, wrong dose, or incorrect dosage form. Pharmacists must check medicines thrice before compounding and dispensing. The main reasons for dispensing errors are improper work environment, work area, workload, distractions, computerized Prescribing Errors, dosage errors, poor labeling, and poor patient counseling.

   The work environment can be improved by providing adequate space, avoiding cluttering of medicines on desks, placing medicines on shelves facing labels forward, improving lighting, maintaining proper temperature, and avoiding humidity and noise. Telephone and TV are the main sources of noise.

   Dispensing errors can be removed by providing sufficient staff and limiting prescription dispensing to not more than 150 prescriptions per day with a 2 to 3-hour break. 

   Computerized Prescribing order entry (CPOE) improves communication and reduces some types of errors Bit it may have its own drawbacks. Such as Lower case letter L may look like the numeral 1, the Letter O may look like the numeral 0 (zero), Letter Z may look like the numeral 2.

   The oral dosage form may be dispensed as an injection. There may be confusion in micrograms and milligrams. 

5. Administrative error: Dispensing of medicines to the wrong patient. Wrong instructions to the patient regarding the quantity of drug to be administered, frequency of medication, route of administration, etc. also lead to medication errors. Pharmacists must be careful during instruction to patients.

Poor patient counseling or poor patient education may cause dispensing errors. Most prescription errors are discovered during Counseling of Patients.  Good Patient Education Inform patients about drug names, purpose, dose, side effects, and management methods Suggest to patients about the right to ask questions and expect.

Steps to Minimise Dispensing Errors

1. Separate drugs that could cause errors

2. Develop and implement proper drug storage (Like arrangement of drugs in Alphabetic orders),

3. Reduce distractions,

4. Design a safe dispensing environment, and maintain optimum work-load.

5. Prevent mix-ups between look-alike and sound-alike drug names,

6. Keep the original prescription order, label, and medication container together throughout the dispensing process,

7. Match the contents of the medicine container label information with the information on the prescription.

8. Enter the drug’s identification code (e.g., National Drug Code [NDC] number) into the computer and on the prescription label

9. Perform a final check on the prescription, the prescription label, and the manufacturer’s container; when possible, use automation (e.g., bar coding) 9. Perform a final check on the contents of the prescription contain

   Perform a final check on the contents of prescription containers.

   Author: Alok Bains