FACULTY OF MEDICINE

DEPARTMENT OF PHARMACY

CHALLENGE IN HANDLING HANDWRITTEN

PRESCRIPTIONS: analysis of some cases and E-prescribing
as an alternative answer

Case Study: Butare University Teaching

Hospital Pharmacy

A Dissertation submitted in fulfillment of

requirements for the award of Bachelor
degree in Pharmacy

Presented by: Theophile NIYITANGA

Supervisor: KAYUMBA Pierre Claver, PhD

Co-Supervisor: BUSUMBIGABO Albert, Phn

HUYE, 5th September 2011

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DEDICATION

This Dissertation is humbly and reverently dedicated

To the almighty God,

To my parents,

To my Sister Génèreuse NIYIGENA,

And to all my friends.

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ACKNOWLEDGEMENT

First, I would like to thank the Almighty God to whom all honor and praise belong. He who
protected me during my studies.

Special thanks go to the Faculty of Medicine, especially the department of Pharmacy, for the
knowledge I got throughout the five years .The realization of this work is the fruit of your effort.

My warmest appreciation goes to my supervisor Dr Pierre Claver KAYUMBA for his tireless
supervision and guidance in the achievement of this work.

I am sincerely grateful to Phn Albert BUSUMBIGABO head of pharmacy department and the
nurses at Butare University Teaching Hospital for their great work, their guidance,
encouragement and commitment that helped me to make this harvest fruitful.

A special note goes to my Sister Génèreuse NIYIGENA who encouraged me in all my

studies, his financial help was of great importance to me. God bless you for all you’ve done to
me.

Furthermore, I would like to express my heartfelt gratitude to my family members: My parents

for the parental love they surrounded me with, brothers for their moral, spiritual and material
contribution.

Finally, I acknowledge the efforts of every friend and relative, all my classmates without
mentioning your names, your moral and material support were highly appreciated.

Theophile NIYITANGA
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ABSTRACT

Objective: To assess handwriting prescriptions challenges during handling prescription in

Butare University Teaching Hospital Pharmacy; root-cause analysis of some cases and E-
prescribing as an alternative answer, in order to improve patient safety and to give a hypothesis
to the upcoming studies.

Methods: This short prospective, direct, descriptive study used the data collected from the
Butare University Teaching Hospital pharmacy, by using a Data collection form, design based on
the current article 54 (delivery of drugs in Rwanda pharmacy) of Law no 12/99 of 02/07/1999
relating to the pharmaceutical art. The sample consisted of all handwritten prescriptions received
(250 prescriptions) during one week period (5 weekdays) from May 23th 2011 to May 27th 2011.

Results: Three root-cases (case1, case 3 and case 6) of handwritten prescriptions challenges
were found with illegible and ambiguous prescribed medicines, others three root-cases (case 2,
case 5 and case 10) of handwritten prescriptions challenges were found with incomplete
handwritten prescriptions, three others root-cases (case 4, case 7 and case 9) of handwritten
prescription challenges, were found with illegible rate of administration of the prescribed
medicines and one root-case (case 8) of handwritten prescriptions challenges was found with
omission of the name, full address of the prescriber and the patient’s name.

Conclusion: Substantial number of handwritten prescription challenges identified at the

Butare University Teaching Hospital pharmacy that reach pharmacists and nurses, have possible
clinical significance. That’s why, implementation of the electronic prescribing and continuing
education of health care providers can minimize those root-cases of handwritten prescriptions
challenges which can cause some medication errors.

Descriptors: Handwritten prescription; root-cases of handwritten prescriptions challenges; e-

prescribing
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TABLE OF CONTENTS
DEDICATION ................................................................................................................................................. iii
ACKNOWLEDGEMENT ................................................................................................................................. iiii
ABSTRACT..................................................................................................................................................... iv
TABLE OF CONTENTS..................................................................................................................................... v
LIST OF TABLES ............................................................................................................................................ vii
LIST OF ANNEXES ....................................................................................................................................... viii
LIST OF ABBREVIATIONS AND ACRONYMS .................................................................................................. ix
Introduction .................................................................................................................................................. 1
Background ............................................................................................................................................... 1
Interest of the study................................................................................................................................... 2
Objectives ................................................................................................................................................. 3
CHAPTER I. LITERATURE REVIEW .................................................................................................................. 4
I.1. HANDWRITING PRESCRIPTION .................................................................................................. 4
I.1.1. Handwritten prescription parties.................................................................................................. 4
I.1.2. Commonly Used Medical Abbreviations .................................................................................... 5
I.2. HANDLING PRESCRIPTION .......................................................................................................... 7
I.2.1. Case of Rwanda ........................................................................................................................... 7
I.3.HANDWRITING PRESCRIPTION CHALLENGES ........................................................................ 8
I.3.1.SOME CASES .............................................................................................................................. 8
I.3.HOW TO REDUCE HANDWRITING PRESCRIPTION CHALLENGES..................................... 13
I.3.1. OVERVIEW OF E-PRESCRIBING ......................................................................................... 13
a) What Is E-Prescribing? ........................................................................................................... 13
b) Important and the Benefits of E-prescribing ........................................................................... 14
c) How E-Prescribing Works ...................................................................................................... 18
d) Perceptions of E- prescribing .................................................................................................. 20
CHAPTER II: RESEARCH METHODOLOGY .................................................................................................... 23
II. 1. STUDY DESIGN ........................................................................................................................... 23
II. 2. STUDY SITE ................................................................................................................................. 23
II. 3. STUDY PERIODE ......................................................................................................................... 23
II. 4. STUDY POPULATION................................................................................................................. 23
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II. 5. INCLUSION CRITERIA ............................................................................................................... 24

II. 6. ETHICAL CONSIDERATIONS ................................................................................................... 24
II. 7. DATA COLLECTION TOOLS ..................................................................................................... 24
II. 8. DATA COLLECTION ................................................................................................................... 24
II. 6. DATA ANALYSIS ........................................................................................................................ 25
CHAPTER III. RESULTS AND DISCUSSIONS .................................................................................................. 26
III. 1. RESULTS ..................................................................................................................................... 26
III. 2. DISCUSSIONS ............................................................................................................................. 29
III.2.1. Root-causes and solutions ....................................................................................................... 29
CHAPTER IV: CONCLUSION AND RECOMMENDATIONS ............................................................................. 34
IV.1. CONCLUSION.............................................................................................................................. 34
IV. 2. RECOMMENDATION ................................................................................................................ 35
REFERENCES ................................................................................................................................................ 37
ANNEXES ........................................................................................................................................................ I
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LIST OF TABLES

Table 1 ………………………………………………………………………………4

Table 2 ………………………………………………………………………………8

Table 3……………………………………………………………………………….9
 viii

LIST OF ANNEXES

Data collection form …………………………………………………………………… II

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LIST OF ABBREVIATIONS AND ACRONYMS

$: United States dollar

%: Percentage

BUTH: Butare University Teaching Hospital

Cp/j: comprimé par jour (tablet per day)

DT: Dose Total

DVT: deep vein thrombosis

E-: Electronic

fl: flacon (bottle)

h: hour

ISMN: isosorbides mononitrate

ISMP: Institute for Safe Medication Practices

j: jour (day)

NSAID: No Steroidal Ant-Inflammatory Drug.

OD: Once daily

PTF/MOH: Pharmacy Task Force/ Ministry of Health

℞: symbol meaning "prescription".

US: United States

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Introduction

Background
Nowadays, one fundamental source of root-causes of handwritten prescription challenge arises
out of the very act of handwriting prescriptions. The assertion that doctors have bad handwriting
holds an honored place in traditional lore.

According to conventional wisdom, doctors write in a code-a self righteous chicken scratch that
is decipherable only by experienced pharmacists and, with luck, by each other. The question of
doctors' handwriting, of course, has a serious side with far reaching implications concerning the
quality and safety of health care. Some studies have found doctors' medical records and
prescriptions illegible, wasteful, and dangerous to the patients. [1]

In handling prescription, an incorrect understanding of the intended drug, dosage, or route or

frequency of administration can quite obviously produce a medication error-not to mention an
adverse drug event.

Sometimes, given some doctors' hurried scribbles, it may be hard for dispensers to tell whether a
zero is preceded by a decimal point or not; if the decimal is misread, the dose ultimately given
may be off by an order of magnitude, and the result could be a 10-fold overdose. On other hand,
poor handwriting can blur critical abbreviations for weights, volumes, or units; µg may be
confused with mg, again leading to an overdose. An order marked as "qd" (once a day) might be
read as "qid" (4 times a day). [2]

However the management of bad handwriting prescriptions continues to pose a major challenge
for pharmacists who may fill the order. In far too many cases the underlying problem is
clinicians' handwriting.

Virtually all of the prescriptions issued each year in the United States are written by hand. And,
indecipherable or unclear prescriptions result in more than 150 million calls from pharmacists to
physicians, asking for clarification, a time-consuming process that could cost the healthcare
system billions of dollars a year in wasted time. At the very least, that process can delay the time
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until patients receive their medications. At worst, a misread order can lead to injury or even
death. [3, 4, 5, 10]

The assessment done in order to determiner frequency of prescription errors in Irish hospital
show that; overall, 27% of individual prescriptions had potential to cause prescription error
because of illegibility or omission of medication administration details. [6, 8]

Based on this notion, this study set the object to assess handwriting prescriptions challenges
in handling prescription in BUTH Pharmacy.

Interest of the study

Illegible prescriptions are a major cause of medication error. They force the person reading the
prescription to make their own interpretation. If that interpretation is wrong the drug may be
incorrectly transcribed by another doctor, incorrectly dispensed by the pharmacist or incorrectly
administered by a nurse.

A study assessing the quality of written inpatient prescriptions found that of 4,536 prescriptions
4 to 10 percent were illegible or ambiguous. [7]
In the US medical practitioners’ sloppy handwriting kills more than 7000 people annually and
the financial costs of drug-related morbidity and mortality may run nearly $77 billion a year,
according to a report from the National Academics of Science, Institute of Medicine. [9, 11]

In our country “Rwanda”, even if there is no data available about handwritten prescriptions
challenges, pharmacists and nurses say that some handwritten prescriptions can cause
miscommunication of drug orders: drugs with similar names like Aciphex (for stomach reflux)
and Aricept (for memory); Allegra (for allergies) and Viagra (for erectile dysfunction) can
create a confusion with the pharmacist if the doctor has not written the prescription neatly. Other
handwritten prescriptions require callbacks to the prescribers in order to read what are written on
prescriptions. [12]
Likewise, others are incompletes and required to send back the patient to the prescriber in order
to complete the prescription.
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This translates into less time available to the pharmacist for other important functions, such as
educating patients about their medications.

It is in the worry to contribute in describing situation of some cases of bad handwritten

prescription in BUTH pharmacy, by revealing some challenges, our pharmacists and nurses face
during handling handwritten prescriptions and show how the alternative to handwritten
prescription, the computer-assisted prescription (E-prescribing) system will create legible
prescriptions that will decrease handwritten prescriptions challenges related to dosing, missing
information, incorrect information, and legibility, that we had carried out prospective, direct,
descriptive study to assess handwriting prescriptions challenges during handling
prescription in BUTH Pharmacy in order to improve patient safety and to give an
hypothesis to the upcoming studies.

Objectives
The main purpose of our study is to assess handwriting prescriptions challenges during handling
prescription in BUTH Pharmacy. To attend this main goal, we intend:

 To determine the number of callbacks done by a pharmacist or a nurse per day, in order
to read what are written on prescription.
 To determine which part of prescription which is omitted or which is hard to read
 To determine the ways used to understand what is written on prescription or to complete
the prescription
 To determine how long it takes to handle handwritten prescription challenge case found,
in order to serve the patient.
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CHAPTER I. LITERATURE REVIEW

In this literature review, we will mention briefly handwriting prescription and its conventional
handling. We will give an overview about how the handling handwriting prescription is done in
Rwanda and emphasize on some handling prescription challenges. We will show some example
of handwriting prescription challenges and how those challenges could be reduced with e-
prescribing.

I.1. HANDWRITING PRESCRIPTION

A prescription is a health-care program implemented by a physician or other medical

practitioner in the form of instructions that govern the plan of care for an individual patient. [13]
Prescriptions may include orders to be performed by a patient, caretaker, nurse, pharmacist or
other therapist. [39]
When it is given out with handwritten instructions from a licensed healthcare provider, such as a
doctor, dentist, nurse practitioner or physician’s assistant, to a pharmacist. These handwritten
instructions are known as a handwriting prescription. [14]

℞ is a symbol meaning "prescription". It is sometimes transliterated as "Rx" or just "Rx". This

symbol originated in medieval manuscripts as an abbreviation of the Late Latin verb recipe, the
imperative form of recipere, "to take" or "take thus". [13]

I.1.1. Handwritten prescription parties

On the handwritten prescription, there is space for your name and address, your age, the date, a
place for your doctor's signature, and a blank area in which your doctor writes the following
directions: [15]
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 Name of the medication

 Dose of the medication
 How often to take the medication
 When to take the medication
 How to take the medication

Additionally, your doctor will indicate how much medicine the pharmacist should give you and
the number of times that your prescription can be refilled.

I.1.2. Commonly Used Medical Abbreviations

Prescriber may use different abbreviations or symbols. The following tables will show some
symbols used and their meaning. [15, 2]
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Table 1. USED MEDICAL ABBREVIATIONS

How Often to Take Your Medication

Abbreviations Intended Meaning
ad lib freely, as needed
Bid twice a day
Prn as needed
O Every
q3h every 3 hours
q4h every 4 hours
Qd every day
Qid four times a day
Qod every other day
Tid three times a day
When to Take Your Medication
Abbreviations Intended Meaning
Ac before meals
Hs at bedtime
Int between meals
Pc after meals
How Much Medication to Take
Abbreviations Intended Meaning
caps Capsule
gtt Drops
i, ii, iii, or iiii the number of doses (1, 2, 3, or 4)
mg Milligrams
ml Milliliters
Ss one half
tabs Tablets
tbsp tablespoon (15ml)
tsp teaspoon (5ml)
How to Use Your Medication
Abbreviations Intended Meaning
Ad right ear
Al left ear
c or o With
Od right eye
Os left eye
Ou both eyes
Po by mouth
s or ø Without
Sl Sublingual
Top apply topically
Often the abbreviation "sig" will appear just before the directions on the prescription. "Sig" is
short for the Latin, signature, or "let it be labeled."[15]
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I.2. HANDLING PRESCRIPTION

One Example when diagnosis is high cholesterol [15]

Zocor 10 mg.
This is the name of the medication and the dose.
Sig: i po qhs
your instructions are to take 1 pill, by mouth, at bedtime.
Dispense #90
you will be given 90 pills, enough for about 3 months.
Refill 0 times
your doctor has indicated no refills, most likely because she would like to check your blood
cholesterol and then decide if you need more medication or a different dose.
DAW left blank
your pharmacist will most likely give you simvastatin, the generic version of Zocor.

I.2.1. Case of Rwanda

In Rwanda, any prescription should be written in duplicate one for the Pharmacist and an other
for the patient and contain the following inscriptions legibly written:

1. Name and full address of the author;

2. Registration number at the professional Association of the prescriber;
3. Date of the prescription;
4. Names, age, weight and sex of the patient;
5. Names of the prescribed products, their form, their administration and their dosage;
6. Signature of the prescriber.

Unless there is a specific note from the prescriber, the validity period of a prescription shall be
limited to one month. [16]

If in a prescription, dosages are not respected, the pharmacist will dispense the drugs after having
consulted the prescriber. If it is impossible for the pharmacist to consult the prescriber, or while
he/she is waiting for the decisions to be made by this one, the prescription will be dispensed
 8

within the limit recommended dosages in the national form. In this case the pharmacist shall
explain to the patient the reasons for changing the dosage in the prescription and the reference to
the new prescriber or any other physician equally qualified. [17]

In case of incompatibility between two or among several prescribed drugs, the pharmacist will
carry out dispersion of the products only after having explained to the prescriber incompatibility
in question shall consist of and proposed a rectification of the treatment accordingly.[18]

I.3.HANDWRITING PRESCRIPTION CHALLENGES

If a pharmacist or a nurse is unable to read the illegible handwriting of a doctor or misreads the
instructions, prescription errors may occur that could be injurious to the patient’s health. If a
patient is receiving wrong medication, there is a possibility that he may develop health problems
other than those for which the prescription was written.
Likewise, if nurses or pharmacists receive an uncompleted handwritten prescription, they ask the
patients to return to the prescriber or they contact the prescriber in order to complete the
prescription. Those entire situations delay the “Five Rights” of medication safety which include
giving the right drug to the right patient in the right dose by the right route at the right time. [38]

I.3.1.SOME CASES

Case 1. A beta blocker can be dispensed instead of an anti-allergy and resulting in strong
reactions.

Dr. N.S. Dixit, a noted heart specialist states that most medication errors in India occur because
of illegible prescriptions; Incidal, the anti-allergy drug can be read as Indiral, a beta blocker.
The later can produce strong reactions in asthmatic patients. [19]
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Case 2. Antidiabetic drug dispensed instead of antibiotic resulting in harm

A man suffered irreversible brain damage after a pharmacist misread his doctor’s prescription.
The patient had been prescribed the antibiotic Amoxil® (amoxicillin) for a chest infection. The
prescription was badly written and the pharmacist misread the drug name as Daonil®
(glibenclamide) a drug used to lower blood sugar in people with diabetes. As a result of taking
the wrong medicine the patient went into a coma and was hospitalized for 5 months. He suffered
blunted intellect and poor short-term memory as a direct result of the medication error. [20]

Case 3. Ten-fold error leading to fatal overdose of epidural diamorphine.

A patient died at a leading private hospital after a prescription was misread. An epidural infusion
of diamorphine was prescribed for post-operative pain relief. The prescription was misread as 30
mg in 10 ml instead of 3 mg in 10 ml by both a nurse and a junior doctor. [21]

Case 4. Ten-fold error in insulin dosing as a result of misinterpretation of prescription

Two patients in different nursing homes received incorrect insulin doses. In both cases the word
‘units’ had been abbreviated to ‘IU’, meaning international units, on the label and on the
medicine administration record. The doses were misread as 61 U instead of 6 IU. The patients
required hospital admission as a result of the ten-fold overdoses. [22]
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Case 5. Fatal confusion between ‘Losec’® and ‘Lasix’®.

A 59 year old woman in a Belgian hospital suffered a cardiac arrest which was attributed to low
serum potassium. Review of the medical record revealed a transcription error. A poorly written
prescription for ‘Losec’®, an ulcer-healing medicine, had been misread and incorrectly
transcribed by a nurse who instead gave the patient ‘Lasix’®, a drug which is known to lower
potassium levels. [23]

Case 6. Istin prescribed instead of isosorbide mononitrate

A patient was discharged from hospital with a supply of isosorbide mononitrate tablets. The
referral letter sent to the Guardian Pharmacist following the patient’s discharge requested that
‘ISMN’ was to be continued. This was misread by the Guardian Pharmacist as Istin®
(Amlodipine) which was subsequently prescribed and dispensed. The error was identified by the
patient who suffered no ill effects. [24]
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Table 2: ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations

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I.3.HOW TO REDUCE HANDWRITING PRESCRIPTION CHALLENGES

According to Institute for Safe Medication Practices (ISMP), those abbreviations, symbols, and
dose designations found in the above tables should never be used when communicating medical
information.
This includes internal communications, telephone/verbal prescriptions, and computer-generated
labels, labels for drug storage bins, medication administration records, as well as pharmacy and
prescriber computer order entry screens.

I.3.1. OVERVIEW OF E-PRESCRIBING

In United States, medication errors such as prescribing or administering the wrong drugs to
patients dropped 66 percent in hospitals that used a computerized system to record doctors'
orders [25]

a) What Is E-Prescribing?

Electronic prescribing or “e-prescribing” is the computer-based electronic generation,

transmission and filling of a prescription, taking the place of paper and faxed prescriptions. [26]

Figure: Electronic prescription view [26]

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E-prescribing allows a physician, nurse practitioner, or physician assistant to electronically

transmit a new prescription or renewal authorization to a community or mail-order pharmacy.
[26]

A “qualified” e-prescribing system must be capable of performing all of the following functions:

 Generating a complete active medication list incorporating electronic data received from
applicable pharmacy drug plan(s) if available.
 Selecting medications, printing prescriptions, electronically transmitting prescriptions,
and conducting all safety checks (safety checks include: automated prompts that offer
information on the drug being prescribed, potential inappropriate dose or route of
administration, drug-drug interactions, allergy concerns, or warnings or cautions).
 Providing information related to the availability of lower cost, therapeutically appropriate
alternatives (if any).
 Providing information on formulary or tiered formulary medications, patient eligibility,
and authorization requirements received electronically from the patient’s drug plan. [26]

b) Important and the Benefits of E-prescribing

E-prescribing offers clinicians a powerful tool for safely and efficiently managing their patients’
medications. Compared to paper-based prescribing, e-prescribing can enhance patient safety and
medication compliance, improve prescribing accuracy and efficiency, and reduce health care
costs through averted adverse drug events and substitution of less expensive drug alternatives.
Taken together, these impacts translate to a higher quality, more efficient health care system that
benefits all. [26]

More specifically, e-prescribing can benefit your patients and practice by:
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1) Improving patient safety and quality of care. There are a number of ways e-prescribing
can reduce medication errors and resultant adverse drug events:

 Illegibility from hand-written prescriptions is eliminated, decreasing the risk of

medication errors and decreasing liability risks.
 Oral miscommunications regarding prescriptions can be reduced, as e-prescribing
should decrease the need for phone calls between prescribers and dispensers.

 Warning and alert systems are provided at the point of prescribing. E-prescribing
systems can enhance an overall medication management process through clinical
decision support systems that can perform checks against the patient’s current
medications for drug-drug interactions, drug-allergy interactions, diagnoses, body
weight, age, drug appropriateness, and correct dosing; and alert prescribers to
contraindications, adverse reactions, and duplicate therapy. E-prescribing software may
also include drug reference software programs, such as ePocrates Rx, Pro, and the
Physicians’ Desk Reference.

 Access to patient’s medical and medication history. Having the patient’s medical and
medication history from all providers at the time of prescribing can support alerts related
to drug inappropriateness in combination with other medications or with specific
medical problems. [26]

2) Reducing time spent on phone calls and call-backs to pharmacies. Physician offices
receive over 150 million call-backs from pharmacies with questions, clarifications and
renewal requests. Medco® Health Solutions, Inc. conducted a survey of Boston area
physicians and 88% of those surveyed said they, or their staff, spend almost one-third of their
time responding to phone calls from pharmacies regarding prescriptions. E-prescribing can
significantly reduce the volume of pharmacy call-backs related to handwriting legibility,
mistaken manual prescription choices, formulary and pharmacy benefits, positively
impacting office workflow efficiency and overall productivity. [26]
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3) Reducing time spent faxing prescriptions to pharmacies. Both prescribers and

pharmacies can save time and resources spent on faxing prescriptions, reducing labor,
handling, unreliability, and paper expense with e-prescriptions. [26]

4) Automating the prescription renewal request and authorization process. Using e-

prescribing, renewal authorization can be an automated process that provides efficiencies for
both prescribers and pharmacies. The staff in the pharmacy generates a renewal
request/authorization that is delivered through the network to the prescriber’s system; the
prescriber then reviews and approves/denies the request, and responds electronically to update
the pharmacy system. With only a few clicks, prescribers can complete renewal authorization
tasks, document that activity and create related staff orders. [26]

5) Increasing patient convenience and medication compliance. It is estimated that 20% of

paper-based prescription orders go unfilled by the patient—at least in part due to the hassle of
dropping off a paper prescription and waiting for it to be filled. By eliminating or reducing this
wait, e-prescribing may help reduce the number of unfilled prescriptions. Allowing electronic
renewal requests can also improve the efficiency of this process, reducing obstacles that may
result in less patient compliance.
Availability of information on when patients’ prescriptions are filled can help clinicians evaluate
and address issues of patient compliance as well. [26]

6) Improving formulary adherence permits lower cost drug substitutions. By checking with
health plan/insurer formularies at the point of care, generic substitutions or lower cost therapeutic
equivalent medications can be encouraged and help reduce patient costs. Lower cost for patients
can also help improve medication compliance. [26]

7) Allowing greater prescriber mobility. Improved prescriber convenience can be attained

when using a mobile device (laptop, PDA, etc.) and wireless network to write or authorize
 17

prescriptions. This allows prescribers to write prescriptions anywhere, even when not in the
office. [26]

Example of allergy warning during prescribing

• 1. Drug selection based on first three letters

• 2. Allergy warning

• 3. Choice to continue or cancel

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8) Improving drug surveillance/recall ability. E-prescribing systems enable automated

analytical queries and reports, which would be impossible with a paper prescription system.
Common examples of such reporting would be: finding all patients with a particular prescription
during a drug recall, or the frequency and types of medication prescribed by certain providers.
[26]

c) How E-Prescribing Works

Creating and managing prescriptions electronically in your practice involves several steps, as
illustrated in the process map below. [26]

Process for Creating and Managing a Prescription Electronically [26]

Signing On
A user of the system—clinician or staff—signs in by performing some sort of authentication to
prove his or her identity. Typical authentication is by username and password, although other
technologies such as random-number cards (SecureID™), digital certificates, or fingerprint
readers are used as well. Once authenticated, the system should know the user’s role and
authorization level to use the prescribing system. Different types of clinicians and office staff
may have different legal permissions to enter, review, or modify prescriptions.
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Identifying the Patient

First, the clinician or staff identifies the patient record within the e-prescribing system.
Patient records can be identified by typing in identifying information (first name, last name, date
of birth, zip code) to the e-prescribing system. If the e-prescribing system is connected to the
registration system, the e-prescribing system can recognize all patient records matching the day’s
schedule, providing a quick, simple way of accessing relevant patient records.

Selecting the Drug, Entering Parameters, Signing, Sending or Printing the Prescription

The next steps in the process correspond to reviewing the medical history, entering, and editing a
prescription. E-prescribing systems should allow clinicians to perform the following functions:

1) Review patients’ current medication list and medication history information:

 Update medication history
 Correct medication history
 Reconcile with multiple history sources

2) Work with an existing medication:

 View details of a medication
 Discontinue or remove a medication
 Change dose, etc., for a medication
 Renew one or more medications

3) Prescribe or add new medication:

 Search for a medication

 From quick choices/favorites
 By name (generic or trade)
 By indication
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 By formulary
 Display medications with prefilled, known, favorite, or standard dosing
 Select medication
 Review warnings
 Enter SIG and other parameters
 Automatically populate and update favorites list of drugs with prefilled known dosing
based on frequency of utilization by clinician

4) complete the prescription and authorize (electronically sign)

 One item
 Multiple items
 Items created by ancillary staff, residents, or others

5) Transmit prescriptions
 Choose print, fax, transmit options in real-time or batch mode
 Print formats and prescription information, conforming to state regulations
 Handle restrictions on certain medications (e.g., class II controlled substances cannot
presently be e-prescribed) Ensure prescription is sent to preferred patient pharmacy
(identified by practice staff prior to interaction with prescriber)

d) Perceptions of E- prescribing

Given the potential advantages of e-prescribing, studies have explored the perceptions of those
who have adopted the use of this technology.

The economic and administrative impact of calls to medical clinics to verify illegible or unclear
instructions on written prescriptions has been explored. One study performed in the Family
Medicine setting showed that 1 year following the adoption of e-prescribing, the overall rate of
 21

after-hours calls was reduced by 22% from baseline (P <0.05), and provider and patient
satisfaction with e-prescribing were reported as "very high”. [27]

Survey studies involving pharmacists have also been performed in the United States regarding
perceptions and acceptance of e-prescribing.
In 1 study, pharmacy staff judged e-prescriptions to be superior in terms of speed of processing
and dispensing, as well as overall (general comparison) when compared with other prescription
types processed (including written, faxed, and phoned prescriptions). [27]

The staffs who were surveyed viewed e-prescriptions as slightly better in terms of impact on
both workflow quality within the pharmacy and the occurrence of drug utilization review issues.
[27]

Other studies have examined patient outcomes and safety with e-prescribing. One study
conducted by the Peace Health Medical Group, a multispecialty physician group, showed an
increase in the number of accurate medication lists, with fewer medication discrepancies
between what the patient was actually taking and what was recorded within the electronic
medical record, when a medication reconciliation system was used in concert with e-prescribing
practices. [27]

Likewise, a survey of physicians indicated that e-prescribers (n = 139) were more likely than
non–e-prescribers (n = 89) to perceive that they could identify clinically meaningful drug–drug
interactions for their patients (P = 0.004). [27]

Studies indicate that e-prescribing may also minimize error rates when physicians write
prescriptions via the tools previously described. A prospective, nonrandomized study compared
prescription error rates between 15 prescribers who adopted e-prescribing and 15 paper-based
prescribers.

For e-prescribing adopters, error rates dropped to 6.6 per 100 prescriptions 1 year after adoption
from a baseline rate of 42.5 per 100 prescriptions (P <0.001), with error rates for non adopters
not changing from baseline to 1 year (P = 0.54). [27]
 22

Overall, studies to date indicate that e-prescribing can help facilitate efficiency and accuracy in
both physician and pharmacy practices. In addition, early adopters of e-prescribing, both in the
medical and pharmacy settings, indicate overall acceptance of this technology.
 23

CHAPTER II: RESEARCH METHODOLOGY

II. 1. STUDY DESIGN

Our study was designed as a cross sectional survey of 1 week. It was a prospective, direct,
descriptive study to assess handwritten prescriptions challenges during handling handwritten
prescriptions, and it referred on outpatient’s prescriptions data from patients who visited BUTH
Pharmacy from 23th May to 27th May, start at 7am-5pm. It was also based on verifying if the
prescribed drugs are legible to the nurses who will dispense the drugs, and if all parties of the
handwritten prescription are completed by the prescriber.

We defined handwritten prescriptions challenges as the difficult that force the persons reading
the handwritten prescriptions to make their own interpretations, and others cases which can delay
the dispensing of the drugs to the patients.

II. 2. STUDY SITE

The study was conducted in the BUTH Pharmacy at Butare University Teaching Hospital. This
Hospital, at the moment of our study, was the one of the referral Hospitals of Rwanda. It
possesses qualified Pharmacists and nurses who receive many patients from different Health
Centres of South-Province of Rwanda.

II. 3. STUDY PERIODE

The study was conducted over a one week period (5 weekdays) from May 23th 2011 to May 27th
2011, start at 7am-5pm.

II. 4. STUDY POPULATION

The study population was constituted by all handwritten prescriptions of patients (250
prescriptions) who were received at Pharmacy Department of Butare University Teaching
Hospital during one week period from May 23th 2011 to May 27th 2011, start at 7am-5pm.
 24

II. 5. INCLUSION CRITERIA

The following inclusion criteria were used for the study; most illegible handwriting prescriptions
and uncompleted handwritten prescriptions, from outpatients who visited BUTH pharmacy
during the week of 23th May to 27th May 2011, which forced the nurses to read the prescription
in order to make their own interpretation and which delayed drugs dispersing, were chosen.

II. 6. ETHICAL CONSIDERATIONS

This study was carried out at BUTH Pharmacy with permission granted from the hospital
management. Privacy and confidentiality of the patient handwritten prescriptions and
prescribers’ address were maintained by using an anonymous data collection form.

II. 7. DATA COLLECTION TOOLS

A restructured data collection form was used during the review of the hand written prescriptions
of the patient who visited BUTH Pharmacy during the week of 23th May to 27th May 2011. And
it was designed based on the current article 54 (delivery of drugs in Rwanda pharmacy) of Law
no 12/99 of 02/07/1999 relating to the pharmaceutical art. [16]

II. 8. DATA COLLECTION

We obtained most of information about handwritten prescriptions challenges from BUTH

pharmacy in Butare University Teaching Hospital by using a Data collection form.
Administrating of Data collection form to the nurses was done by hand-delivering.

During one week of 23th May to 27th May 2011, ten most illegible handwritten prescriptions
and uncompleted handwritten prescriptions cases of outpatients were selected by nurses
themselves from all patients ‘prescriptions received during that week (250 prescriptions). And
each illegible or uncompleted handwritten prescription case was used by a nurse who received it,
to respond to the data collection form. The completed answered data collection form had
returned at the end of the week in order to be analyzed descriptively.
 25

II. 6. DATA ANALYSIS

Firstly, we identified the root-causes of handwritten prescriptions challenges during handling
handwritten prescriptions. We pinpointed four root-causes;

a. The nurses received the handwritten prescription with illegible prescribed medicine.
b. The nurses received the handwritten prescription without the total dose of prescribed
medicine.
c. The nurses received the handwritten prescription with illegible rate of administration of
the prescribed medicine.
d. The nurses received the handwritten prescription without the full address of prescriber
and the patient’s name.
Secondly, we considered like being of no negligible delay in dispensing of all handwritten
prescriptions challenges cases of outpatients received during considering week, from May 23th
2011 to May 27th 2011, start at 7am-5pm.
 26

CHAPTER III. RESULTS AND DISCUSSIONS

III. 1. RESULTS
Case 1: the name of prescribed medicine was totally illegible

The handwritten prescription received in this case was totally illegible to a nurse who received it,
and when she tried to ask her colleague they didn’t figure out what the prescriber wrote. By
using callback to ask the prescriber, they have been informed that the prescribed medicine was
Nootropil® (Piracetam). Then the patient was served after 5 minutes since the arrival to the
Pharmacy.

Case 2: the total dose of prescribed drug was omitted by the prescriber

The handwritten prescription drug was visible but the total dose was omitted. The prescribed
drug was Prednisolone, 100 mg OD. A nurse who received this handwritten prescription after
showing it to her colleagues, she told the patient to go back to prescriber in order to complete the
prescription by putting the total dose which the patient must take. The patient went back to see
the prescriber, but he came back after 10 minutes.

Case 3: the name of prescribed drug was totally illegible

The handwritten prescription drug was totally illegible to the nurse who received it. She tried to
ask her colleagues if they can read what is written on the prescription, but after short period of
confusion they decided to use “REPERTOIRE COMMENTE DES MEDICAMENTS”. Then
they found that the prescribed drug was Lovenox ® 40mg (enoxaparin Sodium injection). The
patient was served the drugs after 5 minutes.

Case 4: the patient was returned to the prescriber for the correction of illegible rate of
administration.

The handwritten prescribed drug was Maxidrol® Collyre, but its rate of administration was not
clear to the nurse. There was confusion if the prescriber wrote “1 goutte/ j/ 12h (2fl) or 1 goutte/
 27

1h/12h (DT=2fl)”. After asking to her colleagues, she didn’t get the clear answer. Then she
decided to ask the patient to return to the prescriber to correct the written rate of administration.
The prescriber wrote clearly that the prescribed Maxidrol® Collyre rate of administration would
be; 1 goutte/ 1h/12h (DT=2fl). This process took 13 minutes in order to serve the patient the
right drug in the right rate of administration.

Case 5: The total dose of handwritten prescribed medicine was omitted

The ampicillin prescribed was clear but the total dose was omitted. The nurse who received this
handwritten prescription, after showing this case to her colleagues she decided to send back the
patient to the prescriber to complete the prescription. The prescriber wrote again the prescribed
medicine which was Ampicillin and he put the total dose also. The patient was served after 12
minutes since his arrival to the pharmacy.

Case 6: the prescribed drug was totally illegible

The handwritten prescribed drug was totally illegible to the nurse who received it. She tried to
ask her colleagues in order to figure out the written drug, but unfortunately they didn’t get it.
After that, she decided to send back the patient to the prescriber to write clearly the prescribed
drug. The patient went back and the prescriber wrote clearly Dicynone cp 250 mg. It took 5
minutes to serve the right drug to the patient.

Case 7: the prescribed drugs were legible but their forms, their administrations rates and
their dosages forms were not clear.

The handwritten prescribed drugs were legible to the nurse but their forms, their administrations
and their dosages were not clear. The prescribed drugs were Amoxicillin syrup (without their
administration and their dosages) and Ibuprofen syrup (without also their administration and
their dosages). The nurse, after realizing this case, first of all she call the prescriber to clarify the
administration rate and the total dosage. Then they decided together to send back the patient to
the prescriber in order to change and to complete the handwritten prescription. The patient went
back to see his Doctor. After thirteen minutes, the patient came back with the new handwritten
 28

prescription; the amoxicillin syrup was changed into amoxicillin gel 250 mg and Ibuprofen syrup
was changed into Brufen cp 200 mg.

Case 8: Name, full address of prescriber and the patient’s name were omitted

The handwritten prescribed drugs were; Ciprofloxacin cp 500 mg and paracetamol 500 mg. But
it was incomplete. The name, the full address of the prescriber and the patient’s name were
omitted. The nurse who received this case, she asked the patient to go back to the prescriber to
complete the handwritten prescription. The patient went back and he came back in 10 minutes
after.

Case 9: the administration rate of prescribed handwritten drug was illegible

The prescribed drug was Quinine but the administration rate was illegible to the nurse. There was
confusion between 500 mg and 300 mg because 5 looked like 3. She called the prescriber to ask
what was written on the prescription and the prescriber decided to bring back the patient in his
office to get the legible prescription of Quinine. He wrote Quinine (300 mg) 3x2cps/j
DT=36cps. After 10 minutes, the patient came back to the pharmacy to get the right drug in the
right dosage form at the right rate of administration.

Case 10: the prescribed drug was legible but the rate of administration was omitted

The prescribed drug was urea 10% (40 g), but the rate of administration was omitted. The nurse
who received it, showed this case to her colleagues then she send back the patient to the
prescriber to complete the prescription. The patient went back and came after 10 minutes to get
the treatment.
 29

III. 2. DISCUSSIONS

To date, most of the literature on the root-causes of handwritten prescriptions challenges show
how those root-causes could cause medication error if those challenges are not
handled.[1,2,3,4,5,6,7,9,10,11]
This is the first study done to assess handwritten prescription challenges in BUTH pharmacy and
in Rwanda. But, because of limited time and finance, the study was short as you have seen and it
was done in order to provide root-causes of handwritten prescription challenges, which will be
used like a hypothesis of upcoming study in this area, and to propose solutions.

III.2.1. Root-causes and solutions

During our survey, we found four root-causes of handwritten prescriptions challenges, which can
cause medication error if they are not handled very well during handling handwritten
prescriptions. As found in Irish hospital study [6, 8], handwritten prescriptions challenges are a
source of medication error if they are not well handled.
As the literature points out that handwritten prescriptions can be illegible and ambiguous [1,7],
forcing the person reading the handwritten prescription had been seen to the nurses who received
case 1,case 3 and case 6.

 On Case 1, the handwritten prescribed medicine “Nootropil” which is used to treat

memory loss, age related memory decline and lack of concentration etc, would be legible
with E-prescribing which show also the specific preparations which may interact with
Nootropil;

 Nootropil may change the effects of blood thinners (warfarin)

 Nootropil in combination with thyroid hormones may cause sleeping disorders,
confusion and irritability. [29]
 30

The remind message will appear on the screen in case the prescriber write Nootropil and
Warfarin on the same prescription. This is an addition of E-prescribing to avoid the
medication interaction. [26]

 On case 3, the handwritten prescribed medicine “LOVENOX®” which helps to reduce

the risk of developing deep vein thrombosis (DVT blood clots), would be read easily with
E-prescribing and it would help to advice the prescriber that the use of aspirin and other
NSAIDs may enhance the risk of excessive bleeding. [31]

 On case 6, the handwritten prescribed medicine “Dicynone” an anti-haemorrhagic

medication, which is able to reduce the bleeding time and blood loss after systemic
and/or local administration, would be read easily with E-prescribing and the patient who
went back to see the prescriber may be she was suffering from “meno-metrorrhagia,”
which is an excessive bleeding from the womb. [36]
E-prescribing could help to stop those movements of patients in instable health state and
it could indicate also that Thiamine (vitamin B1) is inactive by the sulphite contained in
Dicynone 250 for injection. And advise also to inject first of all Dicynone 250 if a
perfusion with Dextran is necessary. [37]

Another root-cause of handwritten prescription challenge is the incomplete handwritten

prescriptions received by the nurses on the case 2, case 5 and case 10. This is a familiar cause of
medication errors in the literature. [6, 8]

 On case 2, the handwritten prescribed medicine “Prednisolone” which is an Intermediate-

acting glucocorticoid that depresses formation, release and activity of endogenous
mediators of inflammation including prostaglandins, kinins, histamine, liposomal
enzymes and complement system which also modifies body's immune response. [30]

The total dose of the prednisolone in this case wouldn’t be estimated by the nurse
because they can’t find the patient clinical case on the handwritten prescription. That is
why they send back the patient to the prescriber who has the patient clinical case
information in the patient file. By using the E-prescribing, those patients clinical cases
 31

information would be shared between prescriber and the pharmacist in order to stop some
errors which cause the patients to go back to the prescriber.[26]

There is high probability that the patient who went back to receive the right total dose,
was suffering from acute gouty arthritis because he delayed in the way. He came back
after 10 minutes. In the meantime, E-prescribing would remind also the prescriber that
Aspirin should be used cautiously in conjunction with corticosteroids in
hypoprothrombinemia. [26, 30]

 On case 5, the handwritten prescribed medicine “Ampicillin” which is an antibiotic used

to treat infections, must be used with caution that why they send back the patient to the
prescriber to receive the right ampicillin dose in order to avoid resistance or the toxicity
due to under dosing or over dosing. It is also important because the ampicillin total dose
used to treat intraabdominal infection is not the same used to treat Pyelonephritis.[34]

By using E-prescribing, as we have seen, the patient clinical data would be shared
between the prescriber and pharmacist in order to stop the patient backward to the
prescriber. E-prescribing would show also the following warning in case the prescribed
medicines may interact with ampicillin;

Allopurinol: Increased possibility of skin rash, particularly in hyperuricemic patients may

occur.

Bacteriostatic Antibiotics: Chloramphenicol, erythromycins, sulfonamides, or

tetracyclines may interfere with the bactericidal effect of penicillins.

Oral Contraceptives: May be less effective and increased breakthrough bleeding may
occur.

Probenecid: May decrease renal tubular secretion of ampicillin resulting in

increased blood levels and/or ampicillin toxicity. [35]
 32

A third root-cause of the handwritten prescription challenges is the illegible rate of

administration of the prescribed medicine received by the nurses on the case 4, case 7 and case 9.
This is also a familiar cause of medication errors in the literature. [1, 2]

 On case 4, the handwritten prescribed medicine “Maxidrol® Collyre” which used to treat
ocular inflammation with suspected or confirmed bacterial infection, must be used with
caution because it’s contain two antibiotics; Neomycin Sulfate , Polymyxin B Sulfate and
a corticosteroid (dexamethasone).
The patient must be sure to use Maxitrol Drops for the full course of treatment. If he/she
does not, the medicine may not clear up his/her infection completely. The bacteria could
also become less sensitive to this or other medicines. This could make the infection
harder to treat in the future. That’s why they send back the patient to the prescriber in
order to receive the right rate of administration. [33, 34]
In this case, E-prescribing would also stop the patient backward to the prescriber and the
delaying of the right time of the treatment, because it will provide the safety chat between
prescriber and the pharmacist or nurse who will dispense the medicine. [26]

 On case 7, the handwritten prescribed medicines “Amoxil and Ibuprofen” which are an
antibiotic and an analgesic/NSAI medicine. There were omission of the total dose and the
rate of administration on the both medicines. That’s why they send back the patient to the
prescriber in order to receive the right dose form and the right rate of administration of
those two medicines. Unsafe use of the Amoxil can cause the resistance and the toxicity.
[40]

E-prescribing will help to stop the patient backward to the prescriber, by reminding the
prescriber that he/she have forgot some important parts of the prescription, and it will
also help to respect the right time of the treatment by providing the rapid-safe chat
between the prescriber and the pharmacist.[26]

 On case 9, the handwritten prescribed medicine “quinine” which is an anti-

infective/antimalarial, used to treat the chloroquine-resistant falciparum malaria;
alternative treatment for chloroquine-sensitive strains of P.falciparum, P. malariae, P.
 33

ovale, and P. uivae. [41] There was confusion about quinine dosage form available in
the country, that’s why they send back the patient, after talking to the prescriber, to
receive the right dosage form (300 mg) at the right rate of administration (3x2cps/jr).
This is done, because unsafe use of the quinine cans worse the situation of malaria
treatment.

By using E-prescribing, the prescriber will use the available update essential medicines
list in Rwanda to prescribe the medications. This will stop the callbacks, the patients
backwards and the waste of time on the both side; the prescriber and the pharmacist. [26]

The last root-cause of the handwritten prescription challenge found during our survey, is the
omission of the name, full address of the prescriber and the patient’s name. This is also another
source of the medication error found in the study done in the outpatients of a Government
Hospital of YOGYAKARTA Indonesia. [42]

 On case 8, the handwritten prescribed medicine “ciprofloxacin” which is an

antibiotic/Fluoroquinolone used to treat various infections. Its use must be well controlled
to prevent some resistance. A study done in Japan showed that the rate of ciprofloxacin
resistance increased from 6.6% in 1993-1994 to 24.4% in 1997-1998.[43]

That’s why the nurses send back the patients on this case, to bring a completed
handwritten prescription in order to prevent Ciprofloxacin resistance, even if the right
time of treatment is delayed.

But with E-prescribing, the prescriber will be reminded by the computer, in order to
avoid those kinds of error and to send the complete prescription to the pharmacist. This
will help to stop also the patient backward and to respect the right time of the treatment.
[26]
 34

CHAPTER IV: CONCLUSION AND RECOMMENDATIONS

IV.1. CONCLUSION

This study showed that a substantial number of handwritten prescription challenges identified at
the BUTH pharmacy that reach pharmacists and nurses, have possible clinical significance.

The most serious handwritten prescriptions challenges were found in the handling those
handwritten prescriptions. We identified four root-causes of handwritten prescription challenges
cases during our survey of the one week, from May 23th 2011 to May 27th 2011, start at 7am-
5pm.

The first root-cause of handwritten prescription challenges cases found was the illegible
prescribed medicines received by the nurses.

The second root-cause of handwritten prescription challenges cases found was the total dose
omission of the prescribed medicine.

The third root-cause of handwritten prescription challenges cases found was the illegible rate of
administration of the prescribed medicines.

The fourth root-cause of handwritten prescription challenges cases found was the omission of the
name, full address of the prescriber and the patient’s name.

All those root-causes of the handwritten prescription challenges had been handled by the
pharmacy staff in order to respect the” Five Rights” of the medication safe, even if there were
delaying in receiving the right medication in some cases.

In handling those root-causes of handwritten prescriptions challenges cases, some callbacks had
been made to the prescribers to handle those handwritten prescriptions challenges cases. The
average callbacks of 0-5 callbacks were used everyday.

On the another hand, after discussing on some cases faced during handling the handwritten
prescription between them, and after calling the prescriber, the nurses sent back the patients to
 35

the prescriber to receive the news prescriptions. This long process delayed the right time of
treatment; on case 7, the patient received his treatment (Amoxicillin and Ibuprofen) after thirteen
minutes.

As a conclusion, the handwritten prescriptions challenges are there in the pharmacy, and they are
delaying the right time of the treatment. That is why some thing should be done to decrease those
challenges on both side; prescribers and pharmacists or nurses, in order to avoid some
medications errors which can be rise from those handwritten prescription challenges cases found.

IV. 2. RECOMMENDATION

At the end of our survey on assessment of handwritten prescription challenges in BUTH

pharmacy, we recommend;

 To ensure training of health staff; prescribers and pharmacists in order to maintain good
health care of the patients by reminding them that there is a current Law no 12/99 of
02/07/1999 relating to the pharmaceutical art which must be respected in prescribing and
in handling handwritten prescription in Rwanda.

 To use of computer program; E-prescribing which allowed prescribers the ability to

choose a medicine from a list of available medications (updated essential medicine list
from PTF/MOH). This system greatly reduces the possibility of writing a prescription
that is incomplete or that contains a formulation that does not exist on the updated
essential medicine list of Rwanda.

This system will improve also drug surveillance/recall ability if the e-prescribing system
is connected to the registration system. The e-prescribing system can also recognize all
patient records matching the day’s schedule, proving a quick, simple way of accessing
relevant patient records.
 36

This is to emphasize that information science can help to create systems which deliver
patient care of higher quality and also keep costs down because they are more efficient.
According of perception of E-prescribing [27].

 To conduct the others study to assess the medication errors which can be rise from the root-
causes found in this study.
 37

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 41

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 I

ANNEXES
 II

DATA COLLECTION FORM

1. How many callbacks done by you per day asking for clarification to the prescriber, in
order to read what are written on prescription?

 Between 0-5 callbacks

 Between 5-10 callbacks

 Between 10-15 callbacks

 Other answers: ……………………..

2. Which part of prescription is it hard to read for you? Or which is omitted?

 Name full address of the author

 Registration number at the professional Association of the prescriber
 Date of the prescription
 Names age weight sex of the patient

 Names of the prescribed products ,their form, their administration and their
dosage
If your answer is names of the prescribed products, what are different names can you
think? (1) ………… (2) ………….. (3) …………. (4) ……………..

3. Which ways do you use to understand what are written on prescription? Or to

complete the prescription?
 I use phone to contact the prescriber
 I ask my colleague

 Other way ………………………………………………………

4. How long it takes to read what is written on prescription in order to serve the patient?

 Between 1- 5 minutes
 Between 5-10 minutes
 More than 10 minutes

REPORTER

Pharmacist Nurse

Supervisor’s name: KAYUMBA Pierre Claver, PhD