Prescription Writing in Small Groups as a Clinical Pharmacology Educational Intervention: Perceptions of Preclerkship Medical Students.

Medical students do not perform well in writing prescriptions, and the 3 variables-learner, teacher, and instructional method-are held responsible to various degrees. The objective of this clinical pharmacology educational intervention was to improve medical students' perceptions, motivation, and participation in prescription-writing sessions. The study participants were second-year medical students of the College of Medicine and Medical Sciences of the Arabian Gulf University, Bahrain. Two prescription-writing sessions were conducted using clinical case scenarios based on problems the students had studied as part of the problem-based learning curriculum. At the end of the respiratory system subunit, the training was conducted in small groups, each facilitated by a tutor. At the end of the cardiovascular system subunit, the training was conducted in a traditional large-group classroom setting. Data were collected with the help of a questionnaire at the end of each session and a focus group discussion. A majority of the students (95.3% ± 2.4%) perceived the small-group method better for teaching and learning of all aspects of prescription writing: analyzing the clinical case scenario, applying clinical pharmacology knowledge for therapeutic reasoning, using a formulary for searching relevant prescribing information, and in writing a complete prescription. Students also endorsed the small-group method for better interaction among themselves and with the tutor and for the ease of asking questions and clarifying doubts. In view of the principles of adult learning, where motivation and interaction are important, teaching and learning prescription writing in small groups deserve a serious consideration in medical curricula.

Pediatric iron preparations for infants in Bahrain: some therapeutic concerns.

BACKGROUND: Infants and children are at a high risk for medication errors. OBJECTIVES: This retrospective study was conducted to determine the type and prevalence of prescribing errors related to pediatric iron preparations prescribed in primary care in Bahrain. METHODS: Prescriptions issued for infants and collected at 20 health center pharmacies for 2 weeks were audited, specifically for errors. RESULTS: Of 2,282 prescriptions dispensed for infants (mean age 9.14 +/- 0.91 months), 159 (7.0%) included an iron preparation. Iron preparations were mostly prescribed (90.6%) with brand names, several of which were neither listed in the primary care drug list nor were available as pediatric dosage forms. 42 (26.4%) prescriptions were issued without specifying the dosage forms, 14 (8.8%) without the duration of therapy and 4 (2.5%) without dosage. Iron dosage was stated as metric volume (ml) and metric weight (mg elemental iron) units in 78.6% and 9.4% of the prescriptions, respectively. The mean elemental iron (+/- SD) prescribed for treating anemia was 4.5 +/- 1.7 mg/kg body weight. A significant difference was observed between physicians and nurses regarding the amount of elemental iron prescribed for treating anemia. CONCLUSIONS: Prescribing of multiple brands of pediatric iron preparations unavailable in the primary care drug list and in pediatric dosage forms, prescribing iron as inconvenient decimal fractions (metric volume units), and omission errors in prescriptions, were common. This may be related to poor communications between the prescribers and the pharmacy services and a lack of information dissemination on newly introduced iron formulations. Moreover, frequent changes in brand availability in primary care may have created confusion for prescribers. The communication between pharmacy services and prescribers should be strengthened, and the procurement of multiple brands should be discouraged. A better management of drug supply and effective policies to minimize prescribing errors are needed in Bahrain.

Prescription writing skills of residents in a family practice residency programme in Bahrain.

PURPOSE OF THE STUDY: To evaluate the prescription writing skill of final year residents in a family practice residency programme (FPRP) in Bahrain, and to compare skill of residents who have graduated from medical schools with problem based learning (PBL) versus traditional (non-PBL) curricula. STUDY DESIGN: Prescriptions issued by the residents were prospectively collected for two consecutive cohorts in May 2004 and May 2005. Prescription errors were classified as errors of omission (minor and major), commission (incorrect information) and integration (drug-drug interactions). RESULTS: In 69.6% of medications with major omission errors, dosage form (39.4%) and length of treatment (18.5%) were not specified. In 24.7% of medications with commission errors, dosing frequency (19.9%) and incorrect strength/dose (2.2%) were the most common errors. Integration errors comprised 5.7% of all prescribing errors. No significant differences were observed between PBL and non-PBL graduates with regard to the total number of prescriptions with errors, drugs per prescription, polypharmacy, and the total number of drugs with errors. The proportion of prescriptions with a potential for drug-drug interactions was comparable between PBL and non-PBL graduates. PBL graduates prescribed medications using brand names at a rate greater than non-PBL, whereas non-PBL graduates prescribed medications on inappropriate "as required" basis, and injections at a rate greater than PBL residents. CONCLUSIONS: Prescription writing skill of the final year residents in an FPRP programme was suboptimal for both PBL and non-PBL graduates. Integration of prescription writing skill and a rational pharmacotherapeutic programme into the FPRP curriculum is recommended.

Assessing prescription writing skills of pre-clerkship medical students in a problem-based learning curriculum.

OBJECTIVE: To audit the acquisition of prescribing skills of pre-clerkship medical students in a problem-based learning (PBL) curriculum that incorporates a prescribing program. MATERIAL AND METHODS: Student performance in pharmacotherapy stations included in six out of eight end-of-unit-objective structured practical examinations (OSPE) was evaluated using a rating checklist. RESULTS: Prescription writing skills of 539 students (66.2% female and 33.8% male) were appraised. With the exception of refill element, the other physician-related components including prescriber's identity, date of prescription order, patient's identity, the symbol Rx "Take Thou", and prescriber's signature were written by 96.1% of the students (95% confidence interval (CI) 94.1 - 97.5). However, the drug-related components such as the appropriateness of drug(s) selected, strength, dosage form, quantity to be dispensed and directions for use were written satisfactorily by 50.2% of the students (95% CI 46.0 - 54.4). With respect to prescribing skills, the mean total score of Year 4 students did not significantly differ from that of Year 2 (69.4 (CI 65.7 - 73.1) vs. 66.3 (CI 62.7 to 69.9); p = 0.237). However, the mean scores of individual drug-related components such as appropriateness of drug(s) selected, dosage form, and direction for use were significantly higher in Year 4 than that of Year 2 students (p < 0.05). Of 381 rationally prescribed drugs, 81.1% were written with generic names. CONCLUSION: This study revealed that the students acquire prescribing skills to a limited extent during the pre-clerkship phase in a PBL program. Prescribing errors and deficits were found to be mainly associated with drug-related components. Further training and assessment of prescribing skills during the clerkship and internship period are needed to achieve mastery of this skill as a terminal competency of graduating physicians.

An evaluation of prescribing errors in primary care in Bahrain.

OBJECTIVES: Prescribing errors are preventable and are considered an important target for improving healthcare. The aim of this study was to identify prescribing errors and their determinants in a primary care setting. METHODS: Prescriptions with errors were collected on a daily basis by the pharmacy staff during the first two weeks of September 2003 in 18 out of 20 primary care health centers in Bahrain. Prescribing errors were classified as omission (minor and major), commission and integration errors. RESULTS: Out of 77,511 prescriptions dispensed, 5,959 (7.7%) were identified to contain errors. The frequency of prescribed medication items in 5,959 prescriptions was 16,091. Of these medications, 13,630 (84.7%) were with errors and only 13.2% were written using generic names. Minor errors of omission such as absence of physician's stamp (34.4%), date (9.8%), and information about patients' address (3.8%), age (3.5%) and sex (0.5%) were not specified. Major errors of omission accounted for 93.6% and were as follows: strength/dose (31.0%), length of therapy/ quantity (29.5%), dosage form (19.7%), and frequency of dosing (13.4%). In 6.3% errors of commission (incorrect information) the most common was strength/dose (3.3%), followed by frequency of dosing (2.6%), dosage form (0.3%), and length of therapy/quantity (0.1%). Major errors of omission associated with topical preparations were significantly higher than those with systemic preparations. However, prescriptions with systemic preparations had a higher rate of commission errors. Significant differences in errors were found in prescriptions ordered by family physicians and general practitioners. In 9.2% of prescriptions with errors, potential drug-drug interactions were expected. CONCLUSIONS: This nationwide survey revealed that in primary care, a considerable proportion of prescriptions contained errors. Strategies to minimize medication errors by improving the prescribing skills, adherence to essential drugs list, and use of National Formulary are needed.

Comparison of the quality of diabetes care in primary care diabetic clinics and general practice clinics.

OBJECTIVES: To compare the quality of care provided to diabetic hypertensive patients by diabetic clinics versus general practice clinics (GP-clinics) in a primary care setting. MATERIALS AND METHODS: A retrospective analysis of medical records of patients from six primary care centres in Bahrain. RESULTS: The recommended target blood pressure <130/85 mmHg was achieved in 6.8 and 10%, and glycated haemoglobin <7% was attained in 14.8 and 11% of patients attending diabetic clinics (n=177) and GP-clinics (n=180), respectively. Although complementary antihypertensive combinations were prescribed at a rate less than that recommended in guidelines, combinations were significantly more often prescribed for patients attending the GP-clinics (46.7% [95% CI 39.4-53.9] versus 33.4% [CI 26.8-40.6]; p=0.01). The prescribing pattern and rank-order of antihypertensive and oral hypoglycaemic agents prescribed, either as monotherapy or in combinations, were similar in both clinics. The majority of diabetic hypertensive patients attending diabetic clinics or GP-clinics were at high cardiovascular risk. Anthropometric characteristics were recorded consistently in patients attending diabetic clinics. Laboratory investigations were extensively utilized for monitoring patients attending diabetic clinics. CONCLUSIONS: In primary care, in both diabetic clinics and GP-clinics, hypertension and diabetes were inadequately controlled, with no difference between the two settings. An integrated approach involving diabetic clinics managed by primary care physicians and nurses trained in diabetes management, and supported by national guidelines, is needed.