Prospective encounter study of the degree of adherence to patient care indicators related to drug dispensing in Health Care facilities: A Sri Lankan perspective.

The World Health Organization-recommended patient care indicators in Government Hospitals were assessed in 422 patients attending the Outpatient Department in selected hospitals of the Galle district in Southern Province. The average dispensing time (ADT), percentage of drugs actually dispensed (PDAD), percentage of drugs adequately labeled (PDAL) and patient's knowledge on correct dosage (PKCD) were compared in these selected teaching hospitals (TH), general hospitals (GHs) and district hospitals (DHs) in Galle. ADT in DH (1.16 min) and GH (1.07 min) were high when compared with ADT in TH (0.81 min). PDAD was 100% in DH, 97.79% in GH and lowest in TH (94.64%). PDAL was highest (22.66%) in TH, 17.57% in GH and lowest in DH (1.57%). PKCD was 100% in GH and lowest in DH (0%) and only 50% in TH in Galle district. We noted that there was a significant difference in ADT in all three categories (P < 0.05). We noted that dispensers spend only a short dispensing time and showed a tendency for dispensing errors. We found that PDAL was very low in all hospitals but PDAD was significantly high. Even though the ADT was high in DH, PKCD was 0% due to negligence in dispensing practices. We also noted a 100% PKCD only in GH due to the practice of a well-prepared correct labeling system in GH. We noticed that these patients were provided drugs with inadequate labeling and that patients had only a poor knowledge about the drug administration schedule. We conclude that there was a low dispenser-patient ratio in all three hospitals and that there was a need for an implementation plan for proper dispensing techniques by introducing a well-prepared drug labeling system in a printed format.

Although modern medicine has changed for better management and good control, evidence still continues to mount about the adverse reactions to medicine. We noticed that the risk associated with dispensing of drugs is one of the major problems in achieving drug safety.[1] There have been drug-induced disasters in the world that have lead to initializing toxicity assays before granting authorization to a drug.[1-4] In addition to that good systemic revies had been done on this field[5] and there are already published data showing the proper guidelines for drug use patterns which are available as references in future studies in the same field.[6] Several studies show that medication errors in prescription, dispensing and delivery had increased the harmful potentials of a drug in the hospital.[7-16] Dispensing errors are generated during the drug dispensing process in the pharmacy. An appropriated dispensing system is an important ally for prevention or reduction of medication errors by helping to minimize dispensing error opportunities in the pharmacy. We decided to investigate the dispensing errors in health facilities and used the patient care indicators created and validated by the World Health Organization (WHO).[1] We planned to perform a cross-sectional survey, considering three types of primary care facilities: teaching hospital (TH), general hospital (GH) and district hospital (DH), and the relevant hospital pharmacies. We selected to study specific parameters like average dispensing time (ADT), percentage of drugs actually dispensed (PDAD), percentages of drugs actually labeled (PDAL) and patient's knowledge on correct dosage (PKCD) because these are the standard parameters recommended by the WHO for analysis of drug use patterns.[12] This paper deals with a qualitative and quantitative analysis in different types of dispensing errors using patient care indicators in primary care health facilities operating in the city of Galle. These tools could be used later as baseline for further follow-up studies in the assessment of quality of drug use.

Materials and Methods

This study was a prospective, comparative, cross-sectional survey. The study was carried out over a period of 6 months at TH, GH and DH. All patients attending the morning clinics in the Out Patient Departments (OPDs) were included in our study. Ethical clearance was granted by the ethics and review committee of the institution. Four hundred and twenty-two encounters were observed by the trained medical students and medical officers . Data collectors were pretrained by the principal investigator as an effort to ensure uniformity in data collection. The patients visiting the OPD from 9.00 am to 10.00 am were selected and existing patient interviews were conducted using a pretested structured observations questionnaire. The following measuring tools were used to assess the degree of patient care and dispensing errors:

Average dispensing time (ADT)

Percentage of drugs actually dispensed (PDAD)

Percentage of drugs adequately labeled (PDAL)

Patient's knowledge on correct dosage (PKCD)

ADT was measured using the total time that a dispenser spent with the patients in the total process of labeling and dispensing. An average calculation of the dispensing time was performed by dividing the total time of all dispensed encounters by the number dispensed.

PDAD is the measurement of drug availability in a health facility. It indicates the degree to which health facilities are able to provide the drugs that were prescribed. This PDAD was calculated by dividing the number of drugs actually dispensed by the total number of drugs prescribed multiplied by 100.

PDAL was one of the other measuring tools to assess the degree of patient care by the pharmacist. It is also important to improve the treatment efficacy of a patient. Labeling is a method of delivery of drug message and can prevent drug-induced toxicities or reactions. It was calculated by dividing the number of drug packages containing drug information by the total number of drug packages dispensed multiplied by 100.

PKCD was used to measure the information delivered to patients about the drugs they receive. The calculation was done by dividing the number of patients who can adequately explain back about the dosage schedule for all drugs by the total number of patients interviewed multiplied by 100.

Statistical analysis

For the descriptive statistics, after having checked the normality of the variables using the Kolmogorov–Smirnov test, the following usual central and dispersion methods were used: average, standard deviation (SD) and 95% confidence interval (CI). The statistical significance of differences among means was evaluated using ANOVA. All statistical analyses were performed using Microcal origin 4.1 and Microsoft Excel whenever applicable.

Results

Different types of dispensing errors in Galle district

Many problems were detected in dispending drugs in the hospitals in Galle district. Dispensing of adequately labeled drugs was 19.38% in general. These medications were dispensed without any administration schedule, quantity, concentration and pharmaceutical name.

Significance of difference in average dispensing time in minutes at different hospital set ups in Galle district

We analyzed 422 patients in whom the patient care indicators were assessed. Figure 1 shows that the ADT was 0.18 min in TH, 1.069 min in GH and 1.156 min in DH. When compared with the WHO recommended value (3 min), these values are lower.[1]

Figure 1

Average dispensing time in minutes (ADT) in different hospitals using ANOVA. ADT in different hospitals were 0.18 min in teaching hospitals (TH), 1.07 min in general hospitals (GH) and 1.16 min in district hospitals (DH), respectively. There a significant difference between these means

Analysis of drug availability by measuring the percentage of drugs actually dispensed

The PDAD is an important index of drug availability in health care facilities. Figure 2 shows that that the PDAD was 94.64% in TH, 79% in GH and 100% in DH. It is also noted that PDAD was low in the tertiary care hospital and high in DH, where only the basic facilities are available.

Figure 2

Percentage of drugs actually dispensed (PDAD) at the different hospitals using ANOVA. PDAD results indicate 94.64% in teaching hospitals (TH), 97.79% in general hospitals (GH) and 100% in district hospitals (DH), respectively

Analysis of percentage of drugs adequately labeled at different health care facilities

PDAL is a good indicator of patient care and quality of dispensing in a health care facility. Our results are important to assess the scope for review educational intervention in dispensing practice in future programmes. The percentages of PDAL were 22.16% in TH, 17.57% in GH and 1.57% in DH, respectively [Figure 3]. Our PDAL in all hospitals was lower than the WHO-recommended values (100%). These data show that adequate labeling practices were higher in TH than in DH, where minimum facilities are available.

Figure 3

Percentage of drugs adequately labeled at different hospitals. Values are given as 22.16% in teaching hospitals (TH), 17.57% in general hospitals (GH) and 1.57% in district hospitals (DH)

Assessment of patient's knowledge on correct dosage at different health care facilities

Percentage of PKCD at different hospitals is an important index for the assessment of standard in dispensing medications in hospitals. Figure 4 shows that the percentages of PKCD were 50% in TH, 100% in GH and 0% in DH. Our values were low in TH, DH and GH.

Figure 4

Results showing that patient's knowledge on correct dosage (PKCD) were different in different health care facilities. Changes in PKCD as shown above in different hospitals were 50% in teaching hospitals (TH), 100% in general hospitals (GH) and 0% in district hospitals (DH)

Discussion

The drug-dispensing system in a health facility needs to be evaluated from time to time so as to increase, mainly, the dispensing efficacy, drug availability and quality of labeling. We found that ADT was short in all hospitals and hence dispensers spent only a short dispensing time in our government hospitals when compared with the WHO-recommended values (3 min).[1] Our values in GH and DH are longer than those in India (0.235 min),[10] Brazil (0.31 min)[12] and Bangladesh (0.38 min).[12] But, the ADT in TH is lower than that in the above countries. Short ADT is one of the many known factors to cause a high risk of dispensing errors. Dispensing time is highest in GH and lowest in TH. Deviations of ADT depend on the strength of the general hospital organizing structure and the attitudes of pharmacists for adherence to the policies of good dispensing practices. We understood that low ADT could be related to the peculiar pharmacist practice of absence of explanation in dosage regimen, precautions and clinically important side-effects of the given drugs. Low ADT could be strongly related to enhance the absence of appropriate labeling.

The results of our study showed an assessment on drug availability. We measured the drug availability by an indirect method, a tool on PDAD. Although the Ideal value should be 100%,[2] it is only achieved in DH. Drug availability is low in GH and TH by PDAD (97% and 94%, respectively). We compared our PDAD values with those from other countries: Nigeria 70%[8] and Nepal 83%.[13] We understood that our values are higher than the values reported from most of the other countries (Cambodia and Ethiopia, ranging from 82% to100%).[1217] Our high rate of PDAD can be explained by effective drug availability in these hospitals, and this has increased patient care and reduced the additional cost to the patient. These data show satisfactory drug supply at the out door pharmacies in Galle District, the credit for which can be given to our national health policy to maintain active chains to maintain good health services to the nation.

Although there is a satisfactory availability, there is a great need for improvement in communications of patients. It has been coupled with lack of a low percentage in drug labeling. We analyzed the percentage of drugs adequately labeled at the different hospitals, and the values were 22.16 in TH, 17.57 in GH and 1.57 in DH. Although there was not a single dispensed drug adequately labeled in an Indian[18] or Cambodian[12] study, much higher figures of 87% in Tanzania[19] have also been reported. In contrast to that, 100% of patients′ knowledge of drugs in DH, despite the low PDAL, can due to significant verbal communications observed by data collectors. It is not due to the good labeling process. In TH, PKCD is 50% and PDAL is very low. This explains that pharmacists have not spent time for verbal communication with the patients despite the low labeling. The absence of name of the drug in the drug packet can lead to a high incidence of adverse drug reaction or drug interaction and reduced therapeutic efficacy. 80.8% of the parents knew the correct drug schedule in India,[10] and this ranged from 55% to 68.3% in Bangladesh and Cambodia.[12]

Patient education should be one of the major activities by pharmacists to improve the rational drug practice with low ADR. Therefore, our data can be used to implement in-service intervention/training programmes for government pharmacists. This study helps us to determine the actual facts for poor labeling and take immediate, suitable implement strategies for the same.

Health care professionals have an important role in patient education, i.e. to receive clear and safe information about drugs. We have observed that correct labeling increased the patient knowledge only in DH. We further found that there is a positive correlation between dispensing time and number of drugs dispensed but no significant correlation between dispensing time and number of drugs adequately labeled (data not mentioned here). This explains that dispensing time is consumed for delivery of drugs but not for labeling. The pharmacist had spent additional time to delivery and handing over the drugs but not improved basic information in labeling.

We understood some limitations. We could not plan to investigate the distribution of different dispensing errors in concentration, dose and dispensed medication and medication dispensed with a wrong pharmaceutical form. We have to plan and classify common errors that would be expanded further in conducting focused group discussions with pharmacists to identify the problems for common identified dispensing errors with in-service intervention programmes. We have planned to expand our study to private pharmacies.

We have a major role in implementing a safe, effective and well-organized drug dispensing system for assuring the safe medical prescription and safe dispensing as requested. It is an importantally to minimize the dispensing errors, thereby protecting the patients from harm and providing cure.