Indian J Stomatol 2014;5(2):41-44

Prescription Writing Skills of Doctors Practicing in Davangere City: A Cross Sectional Survey

Nagesh L1, Wadgave Umesh1, Usha Gv1

Abstract
Aim: Medicines can do a lot of good but they also have the potential to cause harm. Medication errors are one of the most com-
mon causes of patient harm and prescribing accounts for a large proportion of medication errors. Prescribing errors include mis-
takes or inaccuracies when choosing and ordering treatments, such as wrong doses or illegible prescriptions. The present study
was done to assess the prescription writing skills of doctors practicing in Davangere city.
Material and methods: 4 pharmacy shops were selected from each zone of Davanagere city using simple random technique.
Prescriptions dispensed at busy pharmacy shops were collected for a 7 day period. The prescriptions were photo copied and asse-
ssed for the details of patient's information, doctor's information and its legibility using pre-designed criteria.
Results: 397 prescriptions were collected. All the prescriptions were lacking one or more details related to doctors and patient's
information. 37.3% of prescriptions had poor legibility.
Conclusion: This study confirms that the quality of prescriptions being written in Davangere city is unsatisfactory. The situation
is similar in rest of the India as reported in literature. There is a need to standardize the format of prescriptions in India so that all
essential information is included.

Keywords: Prescription; prescription errors; medication errors.

Introduction skills of the practitioners, especially in India. Hence, a stu-

Prescription writing is an imperative part of routine health
practice. Prescription writing is a clinical skill that determi-
nes largely the outcome of a therapeutic decision. An ideal
prescription should include all its important elements to en-
sure a clear and correct communication between a prescri-
ber and a pharmacist. The omission of any of the needed inf-
ormation on a prescription paper could result in miscomm-
unication and prescription errors.
A prescription error is a failure in the prescription writing
process that results in a wrong instruction about one or more
of the normal features of a prescription. The normal features
include the identity of the recipient, the identity of the drug,
the formulation, dose, route, timing, frequency, and durati-
on of administration.1 The suboptimal prescription writing
skill can lead not only to therapeutic failure but also to wast-
age of resources, adverse clinical consequences and econo-
mical loss to both patients and the community.2 Prescription
error is a form of medication error and medication errors are
the most common type of iatrogenic errors. While medicat-
ion errors can occur during drug ordering, transcribing, dis-
pensing, administering, and monitoring, most adverse drug
events (ADEs) (68-75%) occur at the stage of prescription
3
writing or drug ordering. These mistakes involve incorrect
dosing or dosing calculation, incorrect medication, failure
to use best prescription writing practice (e.g., decimal po-
ints, units, and abbreviations), handwriting legibility, and
dosage forms.2
The periodic evaluation of prescriptions can be a good tool
to evaluate the rational use of drugs in terms of prescribing,
dispensing and to evaluate patient understanding regarding
drug usage. Prescription pattern and skills of junior doctors
and students has been reported in the literature. However,
there is a lack of literature or evidence about prescription
1
Department of Public Health Dentistry, Bapuji Dental College and Hospital, Davangere, Karnataka, India.
Correspondence: Dr. Wadgave Umesh, email: dr.w.umesh@gmail.com
dy was conducted to assess the prescription writing skills
of the doctors' practicing in Davangere city.
Material and methods
The present study is a descriptive cross sectional survey
conducted to assess prescription writing skills of the doct-
ors practicing in Davangere city. Ethical approval was obt-
ained from the Institutional Review Board, Bapuji Dental
College and Hospital, Davangere. Permission to conduct
the study was obtained from the selected pharmacy shop
owners. Voluntarily written informed consent was obtain-
ed from all the selected subjects after explaining the purp-
ose and procedures of the study. Subjects who refused to
give consent were excluded from the study.
Sample size determination and sampling procedure
The sample size for the present study was calculated scie-
ntifically based on the data obtained from pilot study. The
prevalence of prescription errors among 20 prescriptions
was found to be approximately 52%. The sample size was
determined by fixing the probability of committing type I
error () at 5% and that of type II error () at 10% thus ma-
intaining the power of the study at 90%. The minimum sa-
mple size calculated was 369.
Davangere city has been divided into 2 zones (North zone
and South zone) for administrative purpose. The same was
used to select the pharmacy shops for the proposed study.
The list of total number of pharmacy shops in Davangere
city was collected from the Drug Control Department, Da-
vangere. A total of 305 pharmacy shops are present in Dav-
angere. 4 pharmacy shops were randomly selected from ea-
ch zone by simple random sampling technique using lotte-
ry dip technique. A total of 8 pharmacy shops were selec-
ted. All the prescriptions which were carried to the selected

41
 Indian J Stomatol 2014;5(2):41-44

Mentioned Not Mentioned

Parameters Frequency Frequency
(Percentage) (Percentage)

Name 321 (81%) 76 (19%)

Age 73 (18%) 324 (82%)
Gender 44 (11%) 353 (89%)
Address 20 (5%) 377 (95%)
Date of birth 25 (6.5%) 372 (93.5%)
Table: 1 Distribution of prescription according to the patient's information

Mentioned Not Mentioned

Parameters Frequency Frequency
(Percentage) (Percentage)
Doctor Name 99 (25%) 298 (75%)
Department name 74 (18.5%) 323 (81.5%)
Signature 297 (75%) 100 (25%)
Contact number 323 (81.4%) 74 (18.6%)

Table: 2 Distribution of prescription according to the doctors' information

Prescription

Scoring Frequency (%)

Score 1 99 (25%)
Score 2 64 (16%)
Score 3 86 (21.7)
Score 4 145(37.3)
Drug Details
Score 1 69 (17.5%)
Score 2 55 (14%)
Score 3 63 (16.5%)
Score 4 206 (52%)

Table: 3 Distribution of prescriptions according

to their degree of legibility

pharmacy shops by patients/others on selected days are in-
cluded in the study. Prescriptions written on the scraps of
-
paper were excluded.
Methods of data collection
A detailed schedule was prepared well in advance. As per
the schedule the collection of prescription forms among the
patients was done for 7 consecutive Saturdays from March
to April, 2013. A photocopy of original prescription was
obtained from all the patients using digital camera. The pr-
escription drugs were checked for the details of patient's in-
formation, doctor's information and its legibility using pre-
designed criteria.5 Prior to conducting the study the invest-
igator was calibrated in order to limit the examiner variabi-
lity. Test retest reliability was assessed on sample of 20
prescriptions and Kappa value was 0.81. The prescriptions
were rated by the single investigator to minimize inter-exa-
miner variability.
Prescribing criteria format
A pre-designed prescription criteria format was used which
consisted of following parameters. They were as follows:
1. Patient information: Name, age, gender, residential add-
ress, date of treatment.
2. Doctor's information: Name of the department, doctor's
name, doctor's signature, doctor's contact number
3. The clarity of the prescription was assessed based on leg-
ibility, which was assessed on 4 point rating system

42

Score I: Prescription details are clear and legible
Score II: Clear but requires effort to read
Score III: One aspect not clear (patient name/drug name)
Score IV: More than one aspect not clear
4. The details of the drugs prescribed were also rated on 4
point rating system
Score I: Clear and legible. Drug details present.
Score II: Clear but requires effort to read
Score III: Criteria not met for one drug
Score IV: Criteria not met for more than one drug
Scoring pattern:
Parameter present score 1, Parameter absent score 0
Legibility: Score I- IV
Drug details: Score I- IV
The data was compiled systematically in Microsoft Excel
spread sheet 2010 and subjected to statistical analysis usi-
ng SPSS software Version 17 (SPSS Inc, Chicago, USA).
The data is presented in frequencies and percentages.
Results
A total of 397 encounters were documented. In relation to
name, 76 (19.1%) were not mentioned in the prescription
letter. Out of 397 prescriptions only 73 (18.4%) encounters
were found to have age groups mentioned. In 353 (88.9%)
prescriptions gender was not mentioned. In 377 (95%) and
192 (48.4%) prescriptions address and date of birth were
missing (Table 1). With regard to the doctor's name majo-
rity of the prescriptions (298, 75.1%) did not have the doct-
or's name. Out of 397 prescriptions 297 (74.8%) and 323
(81.4%) had doctor's signature and doctor's contact numb-
er (Table 2). On assessing the legibility by applying the rat-
ing system 37.3% of the prescriptions were found to have
scored IV attributing to major prescription error. 21.7% sc-
ored III, 16.1% scored II and 24.9% scored I. 52% of the
prescriptions lacked details about drugs (Table 3).
Discussion
Prescribing is the process whereby a doctor, nurse or other
registered professional authorizes use of medications or tr-
eatments for a patient and provides instructions about how
and when those treatments should be used. Prescriptions
are handwritten or computerized documents containing the
patient's name and address, the date, the specific treatments
prescribed and an authorizing signature. They constitute a
way for prescribers to communicate with pharmacists or
others who in turn fill the prescription. Proper prescription
writing, which is an essential skill for doctors in medical
specialties, is the primary intervention that doctors offer to
the suffering humanity. So, prescribing is one aspect of pat-
ient care where it is possible to do considerable harm if not
done judiciously.2
The results of the present study showed that all the prescri-
ptions were lacking one or more details. Among them the
most common error was regarding patient's information.
Such errors might have aroused because of professional
negligence, doing multiple tasks, inadequate staffing, stre-
ssed, tired, busy, emergency situation, night duty, on call
duty, extra-long shifts. Similar results were found in a stu-
dy conducted by audit commission in the year 2001, where
patient's information accounted for 50% of all errors.5
Patient's identity and address are important to ensure that
the correct medication goes to the correct patient and also
Indian J Stomatol 2014;5(2):41-44
for the purpose of identification and record keeping. Pres-
ence of these elements also provides an opportunity to the
pharmacist to contact the concerned patient timely in case
of occurrence of any prescription or dispensing error.2 The
date of prescription is an important part of the patient's me-
dical record that also assists the doctors to recognize the
potential problems including non-compliance. The next
common error was regarding doctors' information (depart-
ment name- 81.5%, doctor's name 75%, signature 25% and
contact number 18.6%). The prescriber's identity and
address on the prescription are essential to ensure a timely
approach by the pharmacist to the physician for a clarific-
ation in case of any confusion.
In our study we found errors related to legibility of prescri-
ptions. Around 37.3% of prescriptions lacked legibility for
more than one aspect of the patient/doctors information.
About 52% of prescriptions lack clarity and legibility in
regard to drug details. This is in conformity with the findi-
ngs of Mendona JM et al. It was found that around 26% of
prescriptions lack clarity and was classified as having low
legibility or as being illegible.11
Inaccuracy in writing and poor legibility of handwriting,
the use of abbreviations or incomplete writing of a prescri-
ption, can lead to misinterpretation by healthcare person-
nel. This can result in errors in drug dispensing and admin-
istration. Inadvertent drug substitution occurs due to the
combination of the physician's illegible handwriting on pr-
escriptions and the pharmacist's misinterpretation of subtle
clues. This will also pose a problem for proper record mai-
ntenance and give rise to many medico legal complicatio-
ns. From the patient's point of view, he/she will not be in a
position to intimate the doctor concerned if a particular br-
and of medicine is not available. This puts the onus of sele-
cting a suitable alternative on the shoulders of the pharma-
cist. These errors can be avoided by pre-printed prescript-
ion pads, training staff assistants who write prescriptions,
printing complete directions on each prescription, and edu-
cating each patient about the name and purpose of all drugs
being prescribed. Patients are encouraged to bring their
medications to each office visit to identify potential errors.
Difficult-to-read handwriting and incomplete medication
orders are important problems that decrease the efficiency
of care and increase the risk for medication errors and pat-
11
ient harm. On the basis of the findings of the present stu-
dy, we recommend implementation of computer medicat-
ion order entry in all the health care centers. Computer me-
dication order entry would ensure legibility and complete-
ness of orders and would help prevent the leading types of
ordering errors, wrong dose, known allergy, wrong freque-
ncy and drug to drug interactions. The findings of our study
along with the similar studies elsewhere in India highlight
the variation, and unsatisfactory nature of the layout and
information contained in the prescriptions. There is a need
to develop and use standardized ideal prescription format
throughout the country. In the present study the difference
in prescription errors of different specialty was not compa-
red. This would be better to know that which specialty peo-
ple make the most errors and tailor the preventive measures
accordingly. We focused only on number of parameters lis-
ted and not on accuracy of the information. Physician relat-
ed component was assessed in the present study. Future st-
udies should focus on drug related components like drug
43

dosage, frequency, route of administration, type of drug.
Conclusion
The results of the present study revealed that doctors acqu-
ire prescribing skills to a limited extent during their train-
ing period. Prescribing errors and deficits were found to be
mainly associated with clarity and legibility components.
Further training and assessment of prescribing skills duri-
ng the clinical clerkship and internship period are needed
to achieve mastery of this skill.
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