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Malaysian Journal of Pharmacy 2003;1(3):86-90 Outpatient Prescription Intervention
Activities by Pharmacists in a Teaching
Chua Siew Siang1*, Kuan Mun Ni1, Mohamed Noor bin Ramli2

1Department of Pharmacy, Faculty of Medicine, University of Malaya, 50602 Kuala Lumpur 2Outpatient Polyclinic Pharmacy Unit, Universiti Malaya Medical Centre, 59100 Kuala Lumpur
*Author for correspondence

Prescriptions with prescribing errors received by an outpatient pharmacy of a
teaching hospital were sampled. The types of pharmacist interventions on
problematic prescriptions and its outcome were identified and documented. From a
total of 6340 prescriptions processed by the outpatient pharmacy in a one-week
period, 43 prescriptions (0.68%) required interventions by the pharmacy staff.
These included 54% of the prescriptions that were incomplete or inadequately
written (errors of omission) and 46% that contained the wrong drug, dose regimen,
strength and dosage form (errors of commission). A total of 62 types of action were
taken by the pharmacy staff to resolve the 43 problematic prescriptions. These
include contacting the prescribers concerned (24.2%), clarifying with the patient or
his/her representative (19.4%), contacting the prescriber’s nurse (17.7%) and
checking the patient’s appointment or identity card (4.8%). Of the 43 problematic
prescriptions, 48.8% were clarified without any change and dispensed while 32.6%
were changed and dispensed. The study reinforces the importance of prescription
screening and interventions by pharmacists in minimising preventable adverse
events attributed to medication errors. It also emphasizes the necessity of
interdisciplinary communication and cooperation in identifying and resolving
prescribing errors and irregularities in order to achieve optimal therapeutic
outcomes for the patient.
Keywords: prescription, pharmacist, intervention, errors of omission, errors of

The dispensing “chain” may be conceptualised A study showed that 99% of the 137 general as a sequence of interrelated, interdependent, and practitioners surveyed agreed that pharmacists at least historically, interdisciplinary activities that result in the delivery of the prescription drug prescriptions for possible problems (2). Most and appropriate drug-use information to the pharmacists would probably agree that the screening of prescriptions is one of the Research article: Outpatient prescription intervention activities by pharmacists professional responsibilities assumed by every 1057 prescriptions per day during the study pharmacist but the degree to which prescription period and was run by one registered pharmacist, screening is performed varies greatly among 3 trainee pharmacists and 8 pharmacy assistants. different drug-delivery systems and even among different pharmacists’ practices. Thus, The study sampled problematic prescriptions prescription screening represents a legitimate received by the OPPD within the one-week value-added pharmaceutical service in practice, period (excluding the Sunday). Senior pharmacy assistants act as the front line for the screening of prescriptions received by this OPPD. Any Many studies had identified and documented problematic prescriptions would be referred to problems associated with prescribing errors. The the trainee pharmacist or the pharmacist. The extent of such errors varied from 2.6% to 15.4% researcher would then record the type of or estimated as 2.87 to 4.9 per 1000 medication intervention made by the pharmacy staff and its outcome prospectively. A standard format pharmacies found that 2.6% of the prescriptions recommended by Rupp (3) was used to record all required active pharmacist intervention to the data. Reasons for pharmacist intervention resolve a prescribing error (1). Another study were classified according to the types of conducted in outpatient pharmacies found that prescribing errors used by Rupp (3), that is errors approximately 4 per 100 dispensed prescriptions intervention (5). In 44% of the intervention, the outcome was a change in drug, strength or Of the 6340 prescriptions received by the OPPD during the one-week sampling period (excluding Most prescription interventions by pharmacists the Sunday), 43 required intervention by the have a limited potential for medical harm although it may be inappropriate in some intervention rate of 0.68% and an average of 7.2 colleagues (7). However, it should be noted that a small number of detected prescribing errors A total of 50 different errors were identified in have a major potential for medical harm if not the 43 prescriptions with an average of 1.2 errors per prescription. Most of the prescriptions had pharmacist interventions is not overemphasized. one error (37 prescriptions) while another 5 had The ultimate goal for combining the unique 2 errors and 1 prescription had 3 errors. These knowledge and competencies of both medical errors are classified as in Table 1 with examples and pharmaceutical professionals is to achieve for each type of errors. Violation of legal or optimal therapeutic outcomes and quality of life procedural requirements such as absence of the for the patient. Therefore, both professions have prescriber’s name or signature, registration a definite role to play and should work hand-in- number for psychotropic agents and patient hand towards achieving this common goal. particulars are also included. The prescription intervened in the category of drug therapy Although most pharmacists in Malaysia are hypokalaemia from the use of LasixR without the interventions to varying degree, documentation of such activities appeared scarce in the literature. Therefore, the present study was A total of 62 types of action were taken by the conducted to identify and document the types of pharmacy staff to resolve the 43 problematic pharmacist intervention and its outcome on prescriptions, giving an average of 1.4 actions per problematic prescription. These include contacting the prescribers concerned (24.2%), This study was conducted over a one-week prescriber’s nurse (17.7%) and checking the period in May 1998 in the Outpatient Pharmacy patient’s appointment or identity card (4.8%). Department (OPPD) of a large teaching hospital in Malaysia. This OPPD received an average of Of the 43 problematic prescriptions, 48.8% were Research article: Outpatient prescription intervention activities by pharmacists Table 1: Classification of reasons for pharmacist intervention.

Reasons for pharmacist
(%, n=50)
T. Pantoprazole 40mg bd T. Daonil 5mg bd T. Imipramine 25mg on Morphine Mixture 10mg tds Glibenclamide od x 12/52 ‘O’ Cephalexin 250mg x 1/12 Dipyridamole 1 tab od x 16/52 Humulin 10 IU tds x 1/52 Zocor 1 daily x 3 mths Patient’s name Captopril 0.25 daily x 2/52 Sy. Prednisolone 25mg tds HCT (hydrocortisone or hydrochlorothiazide) Subtotal
27 (54)
Famotidine 200mg Diamicron 1 gm tds Metformin 80mg bd Thyroxine 200mcg bd Lisinopril 10mg tds Nuelin 5mg on Bactrim 250mg bd x 1/52. Prednisolone 60mg/m2 130mg x 28 days Prothiaden 100mg nocte x 16/52 (only 75mg available) Magnesium sulphate (should be magnesium trisilicate) Humulin R 8IU tds x 8/52 (should be penfill) 23 (46)
Research article: Outpatient prescription intervention activities by pharmacists clarified without any change and dispensed while screening and electronic prescribing may prescriptions were dispensed as written and this standardization of processes and the expanded included the prescription where addition of Slow use of the expertise of pharmacists through better KR was suggested for the patient on LasixR. The integration of the health care team are just as other two prescriptions involved methotrexate 5 mg daily and a prescription with three different types of syrups for a baby. Two patients were The pharmacist or trainee pharmacist had to sent back to the clinics concerned with their contact the prescriber or the prescriber’s nurse 26 problematic prescriptions but did not return times to resolve 23 problematic prescriptions (53% of the 43 problematic prescriptions). This prescriptions could not be contacted. One emphasizes the importance of interdisciplinary prescription was not dispensed as the strength communication and cooperation in identifying requested by the prescriber was not available in the hospital and the patient was asked to buy it irregularities. The community pharmacists in the study by Rupp and colleagues (1) had to contact the prescriber or prescriber’s assistants to resolve DISCUSSION
80% of the problematic prescriptions. This higher rate could be explained by the difference in the sampling frame between the two studies. commission errors (46%) obtained in this study are comparable to that reported by Rupp and screening by the pharmacy staff who were more colleagues (1), with 51% and 29%, respectively. familiar with the prescribing habits of the It should be emphasized that one of the main prescribers in the same hospital. Therefore, the errors in the present study involved wrong dose pharmacy staff could resolve a higher proportion or regimen prescribed (24%). The study by Rupp of the problems encountered without contacting and colleagues (1) showed similar results. This the prescribers than the community pharmacists in the study by Rupp and colleagues (1) who received prescriptions from many different uncorrected. For example, famotidine was prescribed as 200 mg instead of 20 mg. This represents a 10 times overdose if the error has The results also showed that the prescribers not been detected. Decimal points in drug dosage subsequently changed 32.6% of the problematic should also be clearly written especially for drug prescriptions identified by the pharmacy staff. with a wide dose range such as prednisolone that may be prescribed as 2.5mg or 25mg, depending clarified without any change and dispensed. This on the condition of the patient. Additionally, drugs with similar names often cause confusion colleagues (1) that showed similar outcome as in the case of magnesium sulphate being description of 32% and 53.8%, respectively. prescribed instead of magnesium trisilicate. These results further support the importance of Aronson (12) had suggested some measures to preventable adverse events attributed to From the results of the study, the proportion of prescription interventions appeared small Although the present study was conducted in only one hospital, research of such nature could intervention rate of 2.6 and 2.9% had been provide an invaluable database for future recorded (1, 7). Some problematic prescriptions reference and for identifying specific individual especially those with errors of omission may and institutional deficiencies in prescribing. have been dispensed with some assumptions and programmes or institutional procedures could be prescriptions with errors being dispensed to the developed to eliminate the occurrence of such patients without being detected could not be preventable medication errors and to limit the ruled out. The utilisation of information technology via computerization of prescription Research article: Outpatient prescription intervention activities by pharmacists CONCLUSION
in order to achieve optimal therapeutic outcomes prescription screening and interventions by ACKNOWLEDGEMENT
pharmacists in minimising preventable adverse events attributed to medication errors. It also The authors wish to thank the staff of the emphasizes the necessity of interdisciplinary Outpatient Polyclinic Pharmacy Unit, Universiti communication and cooperation in identifying Malaya Medical Centre for their assistance and and resolving prescribing errors and irregularities REFERENCES
Krause JE. Documenting prescribing errors and Hawkey CJ, Hodgson S, Norman A, Daneshmend pharmacist interventions in community pharmacy TK, Garner ST. Effect of reactive pharmacy practice. Am Pharm 1988; NS28: 30-37. intervention on quality of hospital prescribing. Ellis BC, Dovey SM, Collins DM, Tilyard MW, Clark DWJ. General practitioners’ views on the Ingrim NB, Hokanson JA, Guernsey BG, Doutre role of the community pharmacist. N Z Med J Rupp MT. Screening for prescribing errors. Am requirements. Am J Hosp Pharm 1983; 40: 414- Morrill GB, Barreuther C. Screening discharged Schneider J, Leape LL. Relationship between prescriptions. Am J Hosp Pharm 1988; 45: 1904- medication errors and adverse drug events. J Gen 10. Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997; 277: outpatient problem intervention activities of 11. Lesar TS, Lomaestro BM, Pohl H. Medication pharmacists in an HMO. Med Care 1981; 19: 105- prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med 1997; 157: 1569-76. Folli HL, Poole RL, Benitz WE, Russo JC. 12. Aronson JK. Confusion over similar drug names: Problems and solutions. Drug Safety 1995; 12(3): pharmacists in two children’s hospital.


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