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0 DEFINITION The rational use of drugs requires that patients receive medicines appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and the community.dimension process of rational use of medicines involved, appropriate indication, appropriate drug, appropriate administration, dosage, and duration, appropriate patient, appropriate patient information, appropriate evaluation

2.0 STRUCTURE AND FUNCTIONS OF THE MEDICATION USE SYSTEM. The medication use system that is built on the foundation encompasses of the continuum of: Prescribing by the clinician (or self prescribing) followed by transcribing, Preparation and dispensing by the pharmacist, Administering by the provider or consumer (self care), !onitoring for therapeutic and adverse effects (by nurse, surrogate, or self) "o each of these steps may includes critical control points at which decisions and actions can contribute to safety or errors. The primary sta#eholder involve in the medicine use system are Patient$customer and their families, providers, payers, regulators, employers, manufactures, distributors and policy ma#ers. "econdary sta#eholders include accrediting, patient safety and quality improvement organi%ation, medical &ournal and general media. The dynamics of the system for medication delivery are shown, along with relevant sta#e holders in figures below:

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Achieving safe and effective use of medications requires coordinated efforts by all sta#eholders, with mutual recognition that each has unique perspective on what constitute appropriate or rational medication use.Patient$consumers and their families have an interest in maintaining their personnel health and safety at a reasonable cost. Health care prov !er (physicians, nurse practitioners, physician assistants, nurses, pharmacist) have an interest in addressing patient problems effectively and achieving therapeutic ob&ectives. Re"#lator$ have an interest in ensuring the safety of the general public and ta#ing disciplinary action when necessary. %har&ace#t cal &a'#(act#rer$ have an interest in developing and mar#eting new drugs in the service of society and their sta#eholders. %a)er$ have an interest in providing their enrollee with insurance coverage at a reasonable cost. Co&&#' t) phar&ac e$ have an interest in providing patients and consumers with useful information about their medications and averting potential errors. Accre! t '" or"a' *at o' have an interest in assessing health care provides compliance with medical safety standard and best practices. Patient(s safety reporting organi%ations have an interest in collecting data on events and developing protocols to improve safety. Me! cal +o#r'al e! tor$ have an interest in publishing comprehensive and accurate information about medications and their use. A'! the "e'eral &e! a have an interest in writing newsworthy stories about health care and e)posing any problem %RESCRI,ER AND ORDERIN-. The clinicians has the responsibility to engage the patients in discussion about the appropriateness of a prescription drug as part of the treatment plan and about how to design the regimen to meet the patient(s needs. Although the patient should participate in decision ma#ing on whether to use medication therapy, the clinicians retains responsibility for ensuring medically appropriate prescribing and accuracy in medical record documentation and prescription ordering.

+uality and safety in the medication use system require good clinical decision ma#ing about patient care therapeutic option. !oreover all illnesses do not require drug therapy. The need of drug should be evaluated and weighed against alternative treatments to avoid overuse or inappropriate use of medications. ,or instance antibiotics are contraindicated for treating the common cold or viral infection but are often requested and prescribed nonetheless, thus contributing to problem of antibiotics resistance. As another e)amples certain drugs particularly antidepressants, analgesic and muscle rela)ants are commonly and inappropriately prescribed for elderly patients, contribute to adverse drug events that necessitate health care services, physician contact, hospitali%ation, and emergency department visits . -hen the decision is made to select a medication, care is necessary to screen the drug regime for potential drug drug and drug food interaction, age or gender related metabolic or pharmacologic considerations, incidence and severity of side effect, tolerance effect over time, relationship to placebo effect and comparability to other, nonmedication related treatment. Poor decision ma#ing can results in prescribing that fails to help the patient or cause harm. .ven if the correct decisions are made to determining the medication regimen, poor communication of prescription orders in any format (written, oral, electronic) can lead to serious adverse drug events. A number of studies have cited prescribing as a principal source of overall medication errors. The numerous type of prescribing errors identified in the literature includes: The failure to alter drugs therapy in patients with impaired renal or hepatic function ,ailure to notice a patients history of allergy to the prescribe drug class /se of wrong drug name (sound li#e or loo# ali#e) 0ncorrect dosage calculations -rong patients ,ailure to prescribe when there is an indication

,ailure to assess drug interaction or drug food interaction.

,ollowing some report$studies in Tan%ania for contributing success or failure in the effort of promotion of rational use of medicine: Malar a /o#r'al. -# !el 'e$ a'! & '!l 'e$. 0h) !o cl ' cal $ta(($ over1! a"'o$e &alar a ' Ta'*a' a2 A 3#al tat ve $t#!) 2linicians were found to follow mindlines as well as or rather than guidelines, which incorporated multiple social influences operating in the immediate and the wider conte)t of decision ma#ing. 0nterventions to move mindlines closer to guidelines need to ta#e the variety of social influences into account Malar a /o#r'al. Malar a ! a"'o$t c te$t '" a'! treat&e't pract ce$ ' three ! ((ere't Plasmodium falciparum tra'$& $$ o' $ett '"$ ' Ta'*a' a. 4e(ore a'! a(ter a "over'&e't pol c) cha'"e This study shows that an official policy change, where 34Ts were provided and healthcare providers were advised to adhere to 34T results in prescribing drugs can be followed by more rational drug prescribing behaviour. The current findings are promising for improving treatment policy in Tan%anian hospitals. F#t#re &e! c 'e +o#r'al. Re!#c '" '+ect o' over#$e thro#"h co'$#&er$5

pre$cr 4er$5 'teract o'al "ro#p ! $c#$$ o'$ ' Dar e$ Salaa& re" o'6 Ta'*a' a This study show that there was a reducing in&ection overuse through consumers(5 prescribers( interactional group discussions in 4ar es "alaam region, Tan%ania /sing time series in the intervention facilities, the rate of in&ections prescribed fell from 1'6 at baseline to **6 1 months post 074s (p 8 9.9:) DIS%ENSIN4epending on the specific order and patient, preparation of the medication may require counting, measuring or compounding (mi)ing of ingredients) repac#aging (eg. /nit doses) and labeling. Activities associated with preparation present the greatest opportunity for errors involved selection$dispensing of an incorrect drug (eg. ;ecause of

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sound ali#e, loo# ali#e names or pac#aging), dosage strength (e.g. incorrect dilution), formulation (e.g. Tablets versus intravenous medication. Also for =utpatient errors tend to center on incorrect drug labeling information (e.g. use or administration of the drug). 4uring preparation, a large percentage of oral and in&ectable medications used in the inpatient setting require further manipulation (compounding and or$repac#aging) prior to administration, increasing the ris# of error. "ince most drugs are licensed for adult use: reformulation and compounding are most often necessary to treat neonates or paediatric patients who can not swallow tablets or capsules and require dosage concentrations and formulations tailored to their age, body weight and body surface area. 3epac#aging is common for inpatient facilities so as to provide medication in unit doses and thereby minimi%e dose manipulation and error at the bedside. ,urther effort to decrease the error some hospitals used certain automated dispensing system (e.g., ward cabinet) for storing certain medications that are in unit dose form. (eg narcotics, as needed drugs, limited floor stoc#). These systems can be accessed by nurses or personal identification numbers. A patient counseling in pharmacy provides an opportunity for pharmacist to inform the patient about his$her medication, encourage medications adherence and answer any questions the patients may have. Also among of the medication error also may results in dispensing error. !ain causes of these errors are issues concerning wor#load and staff, distractions during processing, suboptimal pac#aging and labeling, poorly design wor# areas and outdated or incorrect drug reference information. ,ollowing some report$studies in Tan%ania for contributing success or failure in the effort of promotion of rational use of medicines ,MC p#4l c health. Malar a treat&e't ' the reta l $ector. 7'o0le!"e a'! pract ce$ o( !r#" $eller$ ' r#ral Ta'*a' a The study show that quality of malaria case management in the retail sector is not satisfactory. 4rug stores should be supported and empowered to provide correct malaria

treatment with drugs they are allowed to dispense. At the same time, the role of general shops as first contact points for malaria patients needs to be re considered. 0nterventions to improve availability of A2Ts in the retail sector are urgently required within the given legal framewor#. A(r ca /o#r'al o'l 'e. Rat o'al ! $pe'$ '" a'! #$e o( arte&ether1l#&e(a'tr 'e !#r '" pre"'a'c) ' Dar e$ Salaa&6 Ta'*a' a The results show that most drug dispensers have inadequate #nowledge about good dispensing practice of A>u in pregnancy. There is therefore a need for continuing training of drug dispensers regarding antimalarial drugs use in pregnancy to promote rational drug use. Ea$t A(r ca /o#r'al o( %#4l c health : To assess the #nowledge of dispensers in private pharmacies on new malaria treatment guidelines which involved switching from chloroquine (2+) to sulfado)ine pyrimethamine ("P) and from "P to artemether lumefantrine? 3esult of the study revealed that lac# of invlolvement of the pharmaceutical personne wor#ing in the Private Pharmacy, from preparation of new malaria treatment guidelinges to their implementation contribute to their poor #nowledge and s#ill on how to correctly dispense the medicines.

ADMINISTERIN- AND CONSUM%TION @urses have primary responsibility for administering medication in acute care hospitals, in long term care facilities, and during home care. 0n most of the areas a nursing assistant$technician may be permitted to administer the selected medications. !any of these setting the environment for nurses is demanding, characteri%e by long wor# hours, staffing shortages, high patient and staff turnover. "o process of accurate administration of medication can be challenging in this environment.

"ince most of the medications are now administered in unit of dose form to minimi%e the amount of compounding by nurses. 0t is ideally medications should be #ept in the dispensing container so as to decrease the ris# of their being confused with another patient(s drug. 0n addition, it is standard practice for a drug label to read three times prior to administration when obtaining from storage area. Perhaps for inpatient patient nurse is often the last professional to evaluate the appropriateness of the medication that has been prescribed. !edication administration is founded on what are termed the five rights 5 right drug, in the right dose, by the right route, at the right time. The type of errors associated with administrations related mortality include.: dosing errors, incorrect drug and incorrect route. 2auses of administration error may include miscommunication, wor#load$staff problems, interruptions, rapid increased in #nowledge and technology demands and incomplete documentation. SE8F ADMINISTRATIONS 9%at e't$: Patients can do a great deal to decrease their chances of e)periencing a medication error. They do not need to spend hours researching their medications and diseases, rather, they need to #now what questions to as# their health care providers, how to insist on answers and how to recogni%e situations that could result in a medication error. ,rom the perspective of consumers the most common types of medication errors are associated with administration of wrong dosage, unnecessary medicating, adverse drug reactions, including drug drug interactions and nonadherance. .rror occur as a results of overdosing and under dosing as a result of inadequate instructions and use of inconsistent or improper measuring devices. ,or e)amples the household teaspoon is device used in most frequently for measuring liquid medication for home administration, instead of dosing syringe. 2ommon error also include misinterpreting instruction, confusing teaspoon and table spoon on a medicine cup and misreading a dosage chart when weight is not typical for a particular age group. The probability of medication dosing error is greatly increased with high ris# medications that have comple) dose regimens such as oral chemotherapy agent, oral anticoagulant,

opiods and insulin. These drugs have narrower therapeutic indices meaning there is less margin for error and the consequence of error may be more devasting. !any dosing error could be avoided with the use of more accurate devices, such as oral dosing syringes, color coding of age weight dosing %ones, particularly for liquid medications administered to children and better presentations of use information and safety warning. The 4a$ c 3#e$t o'$. Mo$t phar&ac $t$ ph)$ c a'$ a'! co'$#&er$ a!vocate$ 4el eve$ that to e'$#re $a(e &e! cat o' #$e all pat e't$ have the a'$0er$ to the (ollo0 '" 3#e$t o'$. -hat is the brand name and generic name of the medication? -hat is the purpose of the medication? -hat is the strength and dosage? -hat are possible adverse effects? -hat should 0 do if they occur? 0 am allergic to . "hould 0 ta#e this medication?

Cow long should 0 ta#e this medication? -hat outcome should 0 e)pect? -hen is the best time to ta#e the medication? Cow should 0 store the medicine? -hat do 0 do if 0 miss a dose? "hould 0 avoid any foods while ta#ing this medication? 0 am also ta#ing DDDDDDDDDDDD (which 0 got at another pharmacy). 2an 0 ta#e both safely? 0s this medication meant to replace any other drug that that 0 am already ta#ing? !ay 0 have written information about this drug?

3ecent article which show the rational used of medicinces:. Dr#" #$e ' pre"'a'c). 7'o0le!"e o( !r#" ! $pe'$er$ a'! pre"'a't 0o&e' ' Dar e$ Salaa&6 Ta'*a' a 0t is evident that drug dispensers and pregnant women in the present study have had low #nowledge regarding the harmful effects of drugs during pregnancy

it was found that availability of pharmacists in the community retail pharmacies was only 1E.E6, an indication that more than half of the drug dispensing personnel in the pharmacies was not professionally trained. Fnowledge of pregnant women concerning the harmful effect of drugs is of great significance. 0ncorrect or insufficient #nowledge may lead a pregnant woman to un&ustified termination of pregnancy, and there is the li#elihood that the fetus may be harmed. 0n the present study, it was found that most of the pregnant women had low #nowledge regarding drug use in pregnancy. The level of #nowledge was found to correlate only with the educational level. INTERNATIONA8 8E;E8 AND NATIONA8 8E;E8 At the international level, drug promotion and mar#eting by the multinational a pharmaceutical company plays a big role in providing information to both health wor#ers and patients through direct advertising. "uch information is often misleading, biased, scientifically inaccurate and always persuasive to encourage over use of particular drugs or brands. The huge investment in 3esearch and 4evelopment by pharmaceutical companies, the role of patent laws and other international trade agreements under The -orld Trade =rgani%ation together with costs of promotion and mar#eting lead to drug prices to be out of reach by the ma&ority of people in developing countries. At the same time, many pharmaceutical companies are not willing to invest in developing countries because these provide a low mar#et potential due to the poor economy and low purchasing power hence limiting accessibility and affordability of drugs to the people who need them. At the @ational >evel wea# laws and regulations in a country encourage dubious individuals with selfish interest to get involved in drug handling and supplies. 7ood laws and regulations provide a frame wor# under which issues concerning drug use are to be handled and monitored and when these are missing result are always chaotic. At the same time such laws and regulations require personnel and equipment to enforce them both of which are significantly lac#ing in developing countries.

The wea# economic conditions in developing countries that has resulted in general poor infrastructure and other economic indices are a cause of the lac# of access to drugs by many in these countries. The following are some of the report$studies at the national on promotional of rational used of medicine Report (ro& & ' $tr) o( health 9Dr#" '(or&at o' 4#llet ': 9pae! atr c ' &e$#l !e $#$pe'!e!:. This was following the controversial reports on the safety of nimesulide, registration of paediatric formulation has been suspended temporarily in Tan%ania until safety profile is thoroughly investigated. These report lin#ing nimesulide and severe liver reactions, especially in children, have been published leading to its withdrawal in some country including "pain, ,inland and Portugal. MONITORIN!onitoring (also referred to as assessment, evaluation, observation, and surveillance) involves obtaining and evaluating clinical indicators and other relevant information to determine a drug(s effect in individual patients. !onitoring for desired and undesired effects is crucial step in the care process and in the prevention or detection of adverse drug events. Pharmacist also may play a role in assessing beneficial or adverse effect during inpatients care, as may patients (including family members) in ambulatory and self care. At best monitoring is individuali%ed, ta#ing into consideration that different patients may e)perience different therapeutic results and outcomes and it is responsive, correcting the regimen if adverse effect is found. Assessing the effect of medications can be accomplished through direct observation of the patients, use monitoring devices and $or information technology. ,ollowing some report$studies in Tan%ania for contributing success or failure in the effort of promotion of rational use of medicine:

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/sing Accreditation and 3egulation to 0mprove 4ispensing and /se of !edicines in 3etail 4rug "hops To address overall issues of rational medicine use, !"C(s "trengthening Pharmaceutical "ystems Program is wor#ing with T,4A to improve appropriate use of medicines in children under five years of age by training dispensers in Filosa district to correctly identify general danger signs and provide appropriate treatment or referral. MEDICA8 AND %HARMACEUTICA8 /OURNA8S. !ost medical and pharmaceutical &ournals depend on advertisement for income from companies that are manufacture drugs or medical equipments. "uch &ournal can not provide totally ob&ective information as articles can not be too critical of the activities or products of the companies. HEA8TH SYSTEMS 8E;E8 The Cealth "ystem inefficiencies disable health wor#ers from performing efficiently to ensure rational use of drugs. 2auses of irrational drug use at the Cealth system level include the followingH /nreliable suppliers of drugsH whose quality and cost of supplies may be questionable Poor planning of the drug needs of the unit Poor infrastructure for storage Poor information management systems >ac# of monitoring and supervision

DIO-NOSIS This can be as a result of inadequate e)amination of client$patient, incomplete communication between client$patient and doctor, lac# of documented medical history etc hence medication error may occur.

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CONC8USION AND RECOMMENDATION The primary sta#eholder involve in the medicine use system are Patient$customer and their families, providers, payers, regulators, employers, manufactures, distributors and policy ma#ers. "econdary sta#eholders include accrediting, patient safety and quality improvement organi%ation, medical &ournal and general media. The promotion of 3/! generally is crucial to ma)imi%e the impact of health care delivery. There are many challenges to 3/! at the diagnosis, prescribing, dispensing, and client$patient use levels e)amples are "ocio economic and political environment of the country, presence of traditional medicine, lac# of trained personnel to implement and sustain the interventions, illiteracy, poor infrastructure and lac# of technology) sta#eholders have #ey roles to play in promoting 3/! at all levels. All

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Re(ere'ce. http:$$www.who.int$medicines$services$e)pertcommittees$pharmprep$-C= A2! 10!PA2T"urvey4ata2ollectionTool3eport.pdf 4r. Fimata 3, Ialimba 3. "he#alaghe ., @#ondo#aya: "upervisory Iisit report: Accredited 4rug 4ispensing =utlets, 3uvuma 3egion, and Tan%ania. ,ebruary to !arch *99B: /"A04 (!"C) June *99B !inistry of Cealth and "ocial -elfare Tan%ania: Paediatric nimesulide suspended. 4rugs information bulletin. *991, ':(*):1 !in% =.!", Caule A.,. Poor #nowledge on new malaria treatement guidelines among dispenser in Private pharmacies: The need for for involving the private sector in policy preparations and implementation: .ast African Journal *99E: : (*): ''B '*' !assele A K, !ashalla K A, Fayombo . J. !waisalage J 4, !wamba @ ., Fani#i 0: 3educing in&ection overuse through consumers(5prescribers( interactional group discussions in 4ar es "alaam region, Tan%ania: Tan%ania Journal for Cealth research, *9'', '1('): GB G*

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Cet%el ! -, 4illip A, >engeler 2, =brist ;, !sechu, J J, !a#emba A !, !shana 2, "chul%e A and !shinda C.: !alaria treatment in retail sector . #nowledge and practice of drug seller in rural Tan%ania: ;!2 public health *99E: E (':B) Famuhabwa A, Jalal 3. 4rug use in pregnancy: Fnowledge of dispensers and pregnant woman in 4ar es salaam, Tan%ania. 0ndian J. Pharmacology !ay 5 June, <1(1): 1<: 5 1<G 2handler 2 0 3, Jones 2, ;oniface 7, Juma F, 3eyburn C,and -hitty 2 J ! 7uidelines and mindlines: why do clinical staffs over diagnose malaria in Tan%ania? A qualitative study: !alaria Journal: *99E: B (:1) Aspden P, Prevention !edication .rror: 0nstitute of !edicine (/.".). 2ommittee on 0dentifying and Preventing !edication .rrors: @atioanal Academy Press:*99B ;astiaens 7 J C, "chafternaar ., @daro A, Feuter !, ;ousema T, "he#alaghe " A :!alaria diagnostic testing and treatment practices in three different Plasmodium falciparum transmission settings in Tan%ania: before and after a government policy change !alaria Journal:*9'', '9 (BA) Famuhabwa 3. !nyusiwalla ,.: 3ational dispensing and use of artemether lumefantrine during pregnancy in 4ar es "alaam, Tan%ania. Tan%ania Journal of Cealth 3esearch: *9'', '1 (*) online

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