Art of writing medical prescription: The devil is in the details

Along with each drug, there is a subscription that describes the dispensing directions often written as either Latin symbols [qd, od, bid, tid, qid, po, hs, etc] or better as instructions in English.
"The pharmacist is the replacement for the old-time apothecary and all drug-related orders in the prescription are to be executed by him."
"The pharmacist is the replacement for the old-time apothecary and all drug-related orders in the prescription are to be executed by him." Maxpixel [Creative Commons]

Prescription is the document on which doctors write the name, dosage, route of administration, frequency, time & duration of drugs/’s for an “index patient”. It also identifies non-pharmacological therapy including diet, lifestyle modifications, and follow-up plans.

Many times, it may include an order for a plan of tests, procedures, and operations as well as a shorter version of medical opinion. Thus, the prescription is the most important piece of paper which patients possess for obtaining relief or cure from their suffering (Fig).

Historical background

Historically prescription was a physician’s instruction to an apothecary (a health professional trained in the art of preparing and dispensing drugs) and listed the materials to be compounded into treatment.

Earlier there were no readymade drugs as today and the apothecary had to prepare the desired drug by mixing various ingredients as per instructions of the physician. 

It starts with the letter R, crossed to indicate an abbreviation (℞ or Rx), meaning Recipere (Latin meaning ‘take thou’ or ‘receive’), and indicated the materials to be compounded. The pharmacist is the replacement for the old-time apothecary and all drug-related orders in the prescription are to be executed by him.

Who is authorized to write a prescription?

A registered medical practitioner (RMP) can file a prescription, including a qualified physician, dentist, or veterinarian. In some countries, advanced practice nurse is authorized to prescribe medication within the scope of his/her practice to prescribe.

Physiotherapists often prescribe medications including painkillers and are governed by laws that differ from one country to another. India has expanded the Indian System of medicine, AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homoeopathy) and of course, qualified practitioners can prescribe medications within the scope of their specialty. A quack is not authorized to prescribe by law yet we encounter it often in our society.

What are the components of a prescription?

A prescription is historically composed of four parts namely superscription, inscription, subscription, and signature.  

Superscription includes patient identification, vital status, clinical syndrome for which appointment has been sought, and physical and patient events that guard the physician to choose the correct drug/s and its dose.

Inscription usually includes the chief drug intended to cure, an additional drug to assist the chief drug, and a supplement (corrective drug) to prevent the adverse effects of the drug.

Along with each drug, there is a subscription that describes the dispensing directions often written as either Latin symbols [qd, od, bid, tid, qid, po, hs, etc] or better as instructions in English.

The signature is usually used for directions to the patient and includes his schedule for the “Return to Clinic” order which again may be in symbols or actual time or date. It ends with a sign from the doctor.

Patient identification

Each prescription must identify an “index patient” through his name which includes surname, first name, middle name, last name, with or without father’s/husband’s name, and a unique number (also named as Medical Record number) generated by the clinic/hospital/institution. In the Middle East, a name can extend to 6 or more words and includes the names of father and grandfather.  Some clinics include a patient’s photo and an ID card. Short of this prescription can be easily exchanged in busy clinics, pharmacies, procedure or operation rooms. Example: If one physician identifies his patient as “B. A.” or “Z. B.”, there is a high chance that there are 2 persons by the same name present at that time in the facility, and the patient who hears the shout of the attendant first, owns the right (lucky) or wrong (unlucky) prescription in the hand of the physician/pharmacist/operator.  There are hundreds of documented examples of exchanges of prescriptions leading to wrong medication, wrong operations, infirmities, and deaths. I remember a senior physician told his patients: “Check your prescription from your doctor today and if you are identified in one [Mr. A.] or 2 [Mr. A. B.] simple words or not identified at all [headless prescription, Mr. X.], you are lucky if this prescription belongs to you.”

Ready access to vital status and events history while writing a drug and its dosage

A prescription often includes many parameters of the “index patient” from the case history in an abridged form. These may be (i). age, sex, and race (in a multi-ethnic society), (ii). vital signs namely weight, height, body mass index, (iii). marital status and pregnancy/no pregnancy for married females of childbearing age (15-45 yr.), (iv). known allergies [to be highlighted at the top], (v). personal habits: smoker/alcoholic, (vi). known diseases like kidney, liver, and heart disease, and (vii). current medications. All these need to be put in an abridged form (for want of space) for easy inspection by the physician while he is writing the next drug and its dose underneath. These data are best documented by trained nurses before a physician’s consult and are placed at the top of the prescription just below the patient’s identification. It helps the physician in the following: (i) determine the correct drug dose (often based on age, sex, body weight, or body mass index); (ii) avoid allergies (from drugs with a high risk of allergies), and drug interactions (when multiple drugs are prescribed and the patient is on drugs from another physician or specialty for chronic illnesses), (iii). safeguard the fetus from teratogenic drugs (causing birth defects, especially when drugs are prescribed in the first trimester of pregnancy), (iv) avoid drugs’ harmful effects on vital organs, especially kidneys (including a large number of drugs commonly used), and if these are necessary to modify their dose as recommended.

Prescriptions to fight against antimicrobial resistance

Resistance to antimicrobial agents has become a major source of morbidity and mortality worldwide.  Bacteria have multiple mechanisms to generate resistance to antibiotics and other antimicrobial agents including limiting uptake of a drug, modification of a drug target, inactivation of a drug, and active efflux of a drug. The main reasons for antimicrobial resistance include overprescribing antibiotics for non-bacterial infections (especially viral respiratory tract infections), over-the-counter (OTC) sale of antibiotics, irrational use of antibiotics (not following standard treatment guidelines), use of poor-quality antibiotics, and lack of compliance with the treatment regimen and course by the patient. Prescriptions are powerful tools to fight these at all levels may be primary care, the private sector, and hospitals. Nurses and pharmacists can play an important role to improve on infection control policies and patient compliance.

Prescription errors

A prescription error can be costly, dangerous, and can lead to death. For example, if we exchange the prescription of a cancer patient for a patient with a cold, death may occur in a healthy person in a matter of days to weeks (Literature has documented many such or similar examples and cases). Would you believe that prescription errors are not uncommon and occur more often than you expect to happen? In the most advanced Medicare system such as in the USA, 1.5 million Americans are harmed per year with 7000 to 9000 deaths through prescription errors and it costs 3.5 billion US $ per year to treat prescription error injuries/illnesses.  In our Medicare system where there is no surveillance for many other things including prescription errors, several studies have highlighted the importance of prescription errors in our healthcare. In one study there were 3935 medication errors in 3 months in a tertiary care hospital, the majority (99.8%) of these were attributed to prescription errors.  In another study, 3.3% of the prescriptions were faulty (wrong drug dose or ineligible handwriting) leading to the majority of the reported medical errors.  The major causes of errors include (i) failure to communicate drug order, (ii) illegible handwriting, (iii) wrong drug selection from drop-down menu, (iv) confusion over similarly named drugs, (v) confusion over similar packing between products, (vi) error involving dosage units or weight. Regularity authorities namely FDA (USA) or CDSCO (India) or the like (other countries) meticulously scrutinize all these issues before a drug is marketed. 

Poor Handwriting or Legibility

It is a known fact that physicians may document prescriptions poorly or unreadable fashion and the pharmacists can’t read the actual name of the drug. Many pharmacists are very smart to guess! the name of the drug written. Many drugs have similar and closely resembling names and can easily be exchanged during dispensing. This phenomenon has put millions of patients on the wrong and sometimes dangerous medication and sometimes barred them from life-saving drugs. The ideal way was to document drug names electronically, however, it is not practiced universally yet due to the difficulties of developing drug modules in each country. Short of that, several things can be practiced by those who cannot write a prescription in optimum legible status: (i) use capital letters, (ii) use both generic and brand name of the drug, (iii) employ a secretary to write drug name and you can only sign it, etc. A senior physician quote: “If you as a patient cannot read the name of the drug on your prescription, you may be at the mercy of pharmacist’s guess to get the correct drug to cure your illness”.

Wrong Drug Dosage

It has been observed that doctors may err sometimes and write inadvertently wrong (over or under) drug dosages in busy clinics. This is more often seen with drugs used uncommonly or newly introduced drugs. This can put patients to risk especially if the drug has a low toxicity threshold, is potentially toxic (like cancer therapy drugs), or a patient has a serious infection or disease (if the drug dosage is below threshold dosage), etc. This is preventable in a good Medicare system as pharmacists should be able to check drug dosage on the software at the time of dispensing the drug. He must be able to call the physician to let him know if the drug dosage prescribed is what he wants.  Thus, pharmacists must have access to make a telephone call to the physician for any doubts about the drug availability, dosage, and instructions. Many clinics/hospitals have an online 24-hour drug information center and physicians can make instant inquiries about drug dosage, toxicities, inter-action, and teratogenic properties.

Spurious Drugs

The spurious drug is a phenomenon seen worldwide since drug company legislation has been relaxed to support trade and business. It is more often seen in the West if drugs are imported from developing countries. In a country like India, spurious drugs are often seen in small urban regions, especially villages. This can be controlled by more stringent legislation of pharmaceuticals, newly introduced drugs or drug formulations, and tighter control by drug control agencies.  In the USA, FDA (Food Drug Administration) has set a high standard to control drug quality and safety over the years, and in India, CDSCO is a reputed organization for its activities.

Drug Safety Information

It is an accepted fact in a good Medicare system that a patient prescribed a drug must be counseled about drug safety, dosage, and toxicity. The mechanism of transmitting this information varies from country to country and from society to society depending upon educational status and awareness. This could be given by a physician at the time of consult, by a counselor in the clinic, or by a pharmacist educated for that and supplemented by pamphlets and other educational material. This helps to pick up drug toxicity very early and can save precious lives.

[This article is an edited version of the chapter published in the book “Dr.Khuroo’s Common Topics on Health & Healthcare”. http://www.drkhuroo.in/archives/Publications/dr.-khuroo-s-common-topics-on-health-healthcare].

DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.

The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.

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