[india-drug] Response to prescribing audits in hospital

[owner-india-drug@healthnet.org]

Response to  prescribing audits in hospital
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Dear Dr. Rao,

>From the practical experiences, a few tips are being presented to bear
in mind while conducting the Core Drug Use Indicators. The intention is
to draw your attention to the prevailing culture/ practices / attitudes
that could pose limitations and possibly a source of bias to the study.

An extensive training would be recommended especially when we are
?training the trainers?. Examining their capabilities to collect data,
their understanding of the reasons for the data collection and also
their ability to train other people should be a mandatory training
module. We all understand that training is necessary, but should be
prepared for extensive training sessions if following the ?train the
trainer? model.

Ours is a culture where doctors have been viewed very highly, have not
been questioned and deemed as the highest source of knowledge
representing a strong profession. In such a culture it is unthinkable
for some pharmacists to be recording the contents of the prescription
by a physician. This seems to be much harder for pharmacists who have
been in the system for a long period. It may not be a bad idea to put
more effort in training neutral personnel for data collection who are
not already caught up in the hierarchy game and feel obligated to not
reveal the real data on the prescriptions.

Training may be needed in more than one language after analyzing the
capabilities of the data collectors. The data collection forms may also
have to be prepared in more than one language to reduce
misinterpretation of the questions in the form. Alterations to the WHO
data collection forms to be made replacing some words with colloquial
language equivalents.
Eg, we had instances where words like ?Seq No? (Sequence number for
recording prescriptions) in the form was not well understood. Also,
?Patient ID No? as used in the standard form, would make more sense to
pharmacists while recording information, if replaced by ?OP No? (Out
Patient Number).

If ample resources exist it may not be a bad idea to get photo copies
of the prescriptions and transcribe data in a more standardized manner
at one central office.

During the field visits what was obvious was that the data collectors
(pharmacists) felt obligated to complete the form in its entirety with
a feeling that they were being tested for their knowledge of the
strength and the dosage of the prescribed drug. It was very hard to
make them understand that they were only to translate the data from the
prescriptions to the form and not to interpret, assume or use their
knowledge base to complete the forms.

In our research design the pharmacists were our data collectors. In
majority of the facilities we noticed that the pharmacists were already
overburdened due to understaffing of the pharmacist positions.
Collecting this data was not a necessity to them and definitely took
the last position on their list of things to do. 
What has been obvious during the field visits is that there is no
common prescription format for the physicians. There are instances when
prescriptions are being written on pieces of paper, newspaper etc.
Prescriptions have been lacking the needed minimum information that may
be needed for the continuity of patient care. Also different ?Chits?
are written for a patient ? one for medicines available within the
facility, sometimes one for the injection room in the facility and one
for medicines to be bought from the private pharmacies. Our already
overburdened pharmacists find it convenient to record data from the
chit that is only presented to them for the drugs and skip the other
two chits that are not presented to them.

While looking for the availability of key drugs in the facilities the
major problems were the stock books not being regularly updated in some
facilities and maintenance of separate log books for drugs supplied
from different suppliers. The absence of pooled stock keeping is a
source of confusion for the data collectors to record the final
quantity of the drug on hand. 

Another point noteworthy to consider is the existence of the hierarchy
of the pharmacy stores in a facility. In some facilities drugs are
signed out / issued from the main storage to the sub-store and from the
sub-store to the dispensary. Stock books are traditionally a
representation of the stock in the main storage. Although the stock
books might indicate a Stock out this may not be true as there could be
a reserve of the drugs in the sub-store or the dispensary. The fact
that there are no guidelines or pattern to the quantity of the drug
that could be issued from one level of storage to the next, we could be
misled if we were to only consider the numbers from the stock book and
not consider the quantity that sits outside the main storage.


Thanking You,
Warm Regards
Aruna Setty

ARUNA SETTY
BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH 
arunasetty@hotmail.com  


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