Standardising Prescription Forms in Jamaica

Dr. Dahlia McDaniel Dickson
A prescription drug order is a lawful written instruction from a licensed physician or other medical practitioner to a licensed pharmacist regarding the compounding or dispensing and administration of drug/s or other medical services to the patient (Shahaibi et al, 2012). In short, it is an instruction from a prescriber to a dispenser. There is no global standard for prescriptions and every country has its own regulations. The most important requirement is that the prescription be clear. It should be legible and indicate precisely what the doctor requires for the patient.

The prescription has eight (8) basic components: Patient Information, Prescriber Information, Superscription, Inscription, Subscription, Signatura, Other Specifications/ Special Instructions, “Pharmacy Use Only” component.

Correct prescription writing has potentially significant influence on the fate of medication therapy and the health of patients. Errors in prescribing may be classified into three main types: Errors of superscription, inscription, and subscription. Prescribing errors may have various detrimental consequences.

Therefore, the components of a prescription should be clearly written, free of drug-related and other omissions (incomplete prescription), free of drug-related commission (incorrect information), and free of nonofficial abbreviation.

Prescription generation and dispensing are governed by regulatory systems, the purpose of which is to maximise the safety and efficacy of the product supplied. The components together should fulfill the legal requirements of a prescription.

The Pharmacy Act/ Regulations of Jamaica (1975) states that:

“Every prescription for a drug shall include the date, name, age and address of the person for whom the prescription is issued; the name, the generic name, and the quantity of the substance to be supplied; adequate directions for the use of the substance prescribed; the usual signature of the prescriber and his name in legible print form; the address, telephone number and registration number of the prescriber”.

Pharmacists have an important role in checking prescriptions to ensure that they are appropriate to dispense. The prescription screening and interventions by pharmacists are crucial in minimising preventable adverse events attributed to medication errors.

Interdisciplinary communication and cooperation is necessary to identify and resolve prescribing errors and irregularities in order to achieve optimal therapeutic outcomes for the patient.

Legal Obligation to Write Clearly
Inaccuracy in writing and poor legibility of handwriting can lead to misinterpretation by healthcare personnel (Velo and Minuz (2009).

Medical Doctors are legally obliged to write clearly, as emphasised in one UK Court of Appeal ruling (The Times, 1988). A doctor had written a prescription for Amoxil tablets (amoxicillin). The pharmacist misread this and dispensed Daonil (glibenclamide) instead. The patient was not a diabetic and suffered permanent brain damage as a result of taking the drug.

The court indicated that a doctor owed a duty of care to a patient to write a prescription clearly and with sufficient legibility to allow for possible mistakes by a busy pharmacist. The implications of this ruling are that doctors are under a legal duty of care to write clearly, that is with sufficient legibility to allow for mistakes by others.

The courts will be prepared to punish the careless by awarding sufficient damages when illegible handwriting results in a breach of that duty, causing personal injury. Liability does not end when the prescription leaves the doctor’s consulting room. It may also be a cause of the negligence of others (The Times, 1988).

Handwritten Prescriptions in Jamaica
Medical doctors in Jamaica work under time pressure and often hurriedly sign their names. The resulting illegible prescription and signature create a number of challenges for patients, their caregivers and pharmacists. The considerable time and frustration associated with this detective work far outweighs the extra effort needed to dot an ‘i’ or cross a ‘t’. Trying to save time by writing quickly is thus a false economy (Sokol and Hettige, 2006).

Seventeen years ago the Institute for Safe Medication Practices (2000) stated that in the United States then, prescription writing was perhaps the most important paper transaction remaining in their increasingly digital society.

In Jamaica today, the vast majority of prescriptions are handwritten, which creates challenges. Anecdotal evidence provided by pharmacists in two recent (2016) newspaper articles highlight some of these challenges.

A December, 2016 Gleaner newspaper article titled, “Medical Mess Up! – Careless Doctors Aiding Prescription Fraud”, suggests that doctors break the law by not ensuring that their names and registration numbers are clearly visible on all their prescriptions, and that this contributes to prescription fraud in Jamaica. As expressed in the same article, the President of the Medical Association of Jamaica conceded that some doctors have developed the habit of not writing their names on prescriptions and suggested that greater reinforcement may be needed.

Another stakeholder, Sagicor, a health insurance company, weighed in on the issue, when its representative maintained in that article, that the pharmacist should insist that the prescriber’s name and registration number be on the prescription as required by law. Sagicor’s representative bolstered the company’s position by stating that Sagicor cannot process a health insurance claim for medication, without the identity of the prescriber.

In a previous Jamaica Observer newspaper article titled, “Doctors Please, Bad Practices Need to Stop”, by Mrs. Shereen Dawkins Cox, president of Jamaica Association of Private Pharmacy Owners, (November 2016), states that omission of prescriber’s identification on a prescription creates a problem for pharmacists to identify fraudulent prescriptions – as opposed to genuine ones.

She spoke to the issue of illegible handwriting, and how this was compounded by the pharmacist’s inability to identify the prescriber, since clarification of dubious or ambiguous items on a prescription could only be achieved by communicating with the prescription writer.

Dawkins Cox (2016) explained in her article, the gravity of the pharmacists’ challenges with illegibility and omissions:

“There are times when the medication’s name, dosage strength, frequency and directions are not clear, and as pharmacists we cannot legally make a change on the prescription without first contacting the prescriber. Many times we may be able to identify the health facility, but on calling we cannot identify the actual prescriber in order to communicate these errors”.

Prescriber Factors
Prescribers must own their work. For those prescribers who do Their handwriting behaviours pose a challenge to pharmacists and patients.

Prescribers will need to be enlightened on the impact of their omissions and their illegible handwriting.

Pharmacist Factors
Pharmacists must own their work. This includes upholding the requirements of the Pharmacy Act. In order to elicit change in prescribers’ behaviours, a zero-tolerance approach may be necessary regarding the dispensing of prescriptions that do not bear the required components.

Patient Factors
The health facility being identified is a start, but in many instances the location of the prescription writing/writer cannot be established since the client tendering the prescription is a caregiver or bearer, and not the patient who saw the prescriber. In other cases, the prescription form used is one generated by a private facility such as a community retail pharmacy or drug manufacturer/distributor for the purpose of advertising the entity.

The majority of patients who present to the pharmacies after visiting public sector health facilities do not know the name of the prescriber who administered treatement. Indeed, in many instances the prescriber changes with each visit based on the monthly rota.

This underscores the point that patients have a right and a responsibility to know the identity of their prescribers. The patient, who is one player in his/her health care, is a crucial link between health professionals. Additionally, in cases concerning liability of the health professional, the patient should be able to identify the health professional who attended to him/her.

This is the era of customer sovereignty, where customers are rightfully insisting on getting exactly what they paid for, including a decent meal in a hospital and courteous, timely delivery of service in the doctor’s office or pharmacy. Consumers and patients want to know more about the food they consume and the drugs they take — their appetite for information is growing. However, with all this comes the responsibility to know the names of the prescribers of their medications.

Dawkins Cox (2016) addresses this in her article:

“It is the fundamental right of the patient to know that the individual offering care is a qualified doctor and the identity of that prescriber should be forthcoming. It is unfortunate that a white coat and stethoscope and the name doctor is all we need.”

When the pharmacist asks a patient about the name of his/ her prescriber, the answer that the patient gives, cannot necessarily be taken as credible, but in some instances, where the pharmacist is able to partially ‘decipher’ the prescriber’s signature, the patient’s response may help to elucidate, confirm or rule out the pharmacist’s hunch.

Treatment Delayed Is Treatment Denied
In the USA, Sokol and Hettige reported in 2006 that indecipherable or unclear prescriptions resulted in more than 150 million calls from pharmacists to physicians, asking for clarification, a time-consuming process that was estimated to cost the healthcare system billions of dollars a year in wasted time. At the very least, that process delayed the time until patients receive their medications.

The same principle applies to prescriptions in Jamaica. There are two main challenges:

  1. Firstly, since the pharmacist should not fill a prescription if he/ she is not sure of the identity of the prescriber, when any piece of information therein is missing or not decipherable, or unclear, the pharmacist tries to assist the patient by making contact with the prescriber. This time-consuming process is even longer when the prescriber’s identity is also unclear and his/ her registration number is unclear or missing. In some cases the prescription is decipherable and clear but the prescriber’s signature and/or registration number are not.
  2. For clients who use a health insurance plan at the pharmacy, insurance companies require the correct prescriber’s name to be included on the insurance claim.

Dawkins Cox explained this in her Observer newspaper article:

“When the prescriber information is missing, deficient or not registered on the insurance system, pharmacists are challenged to select the correct prescriber in order to submit the claim. When a pharmacist is unable to select the prescriber the patient may not be able to utilise the benefits of the insurance card and eventually may have to pay more out of pocket or the prescription is not filled at all.

In circumstances when the prescriber cannot be identified or located, the patient or caregiver oftentimes has to return to the health facility to have corrections made.”

In the 2016 Gleaner article, the representative from insurance company Sagicor stated, “If the prescriber is unable to be identified either by name or by number, the pharmacist is unable to submit the claim to the insurance companies. Not only do insurance companies need this information, but the pharmacist also needs to know that a properly qualified and registered doctor is writing the prescription.”

In that same article I explained that I am in the business of protecting the patient’s health, so I would not try to sell them medications (with missing information) at whatever cost. I argued that when I refused to fill such prescriptions, my pharmacy business as well as the patients suffered.

So, when pharmacists cannot identify doctor, in many cases they cannot locate the doctor. To the patient this has one major meaning — inconvenience, since the patient is now asked to go and find the doctor, which may delay the treatment for days or weeks.

Automated Prescribing Systems and Standardised Prescription Forms
The complexity of the prescribing procedure may be reduced by introducing automated systems or uniform prescribing charts and prescription forms, in order to avoid transcription and omission errors.

Pharmacy Council Chairman, Dr Norman Dunn who stated that the doctor’s failing to write their names clearly is long-standing, and has been discussed with the Medical Council of Jamaica, also endorsed electronic prescribing, suggesting that a fully electronic system could be the answer (Jones, 2016). He said it would reduce the incidence of fraud, and the pharmacist’s inability to identify the prescriber.

Electronic (automated) prescribing has been introduced to public health stakeholders in Jamaica since 2015. The Pharmacy Council of Jamaica, Drug Importers and Distributors and Pharmacists have been sensitised to this practice, which adjudicators of such systems propose, will be a win-win for all concerned – the pharmacists and pharmacies, medical doctors, medical centres, public health laboratories, radiology units, physiotherapists and health insurance providers, and most importantly the patients and their care-givers. Electronic prescribing may a plausible solution to the immediate and resultant challenges posed by prescription writing (incomplete prescriptions and incorrect information), prescription fraud, the pharmacist facing difficulty or inability to read prescriptions, and to contact the prescriber.

However, in Jamaica electronic (automated) prescribing is not officially practised to date, and it may take several years to begin. Up to 2006, although most hospitals in the USA were equipped with devices to produce electronic prescriptions, only 5% of prescriptions were ‘written’ electronically (Sokol and Hettige, 2006).

It is reasonable to expect that handwritten prescriptions will continue to be a popular option for several years after electronic prescribing is introduced to Jamaica. Until such time, a practical solution is the standardised prescription form.

The standardised prescription form is one which is designed with a space, compartment or slot in which to write all of the required components of prescription. ‘Standardised’ suggests that all prescribers will be expected to use a form which is similarly designed to a uniform standard. It is created to encourage the prescriber, when writing a prescription, to include all the required components of the prescription.

The inclusion of some components of the ‘standardised’ prescription form may improve prescribers’ compliance with the Pharmacy Act regarding name and registration number. Some pharmacists have noticed that prescription forms which provide slots designated and labeled, for Doctor’s Name, Registration Number and Doctor’s Signature, yield more of these essential data from the prescribers.

Proposed Benefits of Having a Standardized Prescription Form

  • It will Decrease the Work Required to Execute a Prescription
  • It will Reduce the Time Spent By Pharmacists on Phone Calls and Call Backs
  • It will Improve Patient Convenience and Medication Compliance

By: Dr. Dahlia McDaniel Dickson

References

Medical mess-up! – Careless doctors aiding prescription fraud – Sunday December 4, 2016, Ryan Jones

Doctors, please, bad practices need to stop! Jamaica Observer Newspaper,Tuesday, November 15, 2016

http://www.jamaicaobserver.com/pfversion/Doctors–please–bad-practices-need-to-stop-_80446#ixzz4WKNZGYVI

Medication Errors: Prescribing Faults and Prescription Errors, Velo, G.P. and Minuz, P.

British Journal of Clinical Pharmacology, June 2009

Poor Handwriting Remains a Significant Problem in Medicine. Sokol, D. and Hettige, S. Journal of the Royal Society of Medicine (2006). 99(12): 645–646.

A Call to Action: Eliminate Handwritten Prescriptions Within 3 Years! Electronic Prescribing Can Reduce Medication Errors

Copyright © 2000 by the Institute for Safe Medication Practices. All rights reserved.

Identifying Errors in Handwritten Outpatient Prescriptions in Oman. Shahaibi, N, Said, L., Kini, T.G., and Chitme, H.R. Journal of Young Pharmacists 2012, Oct-Dec; 4(4): 267–272.

Prendergast v Sam & Dee Limited, The Times 24 March 1988

About the author: Shari-Lee Johnson