How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions

Older adult patient preferences for the content and format of prescription medication labels - A best-worst scaling and discrete choice experiment study

BACKGROUND

Patient preferences for the content and format of prescription medication labels (PMLs, i.e., sticker labels placed on medication bottles/packets at dispensing) have been extensively studied. However, accommodating all preferences on PMLs is impractical due to space limitations. Understanding how patients prioritise the content and format attributes of PMLs can inform improvements while working within PML space constraints.

OBJECTIVES

We aimed to (1) identify a ranking of medication-related content attributes to be prioritised on PMLs using best-worst scaling (BWS), and (2) determine the relative importance of format attributes when incorporated onto PMLs using discrete choice experiment (DCE), from the perspective of older adult patients in Singapore.

METHODS

Attributes were informed by our prior qualitative study and PML best practice guidelines. For the BWS component, the assessed content attributes were indication, precautions, interaction or paired medicines, food instructions, side effects, expiry date, and missed dose action, all of which are currently not legally mandated on PMLs in Singapore. A BWS object case was used to rank the content attributes. For the DCE component, in a series of questions, participants were asked to choose between two PML options each time, that varied in the presentation of dosage-frequency instructions, font size, presentation of dosage, presentation of precautions, and font colour of precautions. A mixed logit model estimated the relative utilities of format attribute levels, enabling the calculation of importance scores of the format attributes.

RESULTS

The study recruited 280 participants (mean age: 68.8 ± 5.4 years). The three most-preferred content attributes were indication, precautions and interaction or paired medicines. The top three format preferences were tabular style presentation of dosage-frequency instructions, large font size and precautions in red colour.

CONCLUSIONS

Healthcare institutions should consider improving their PMLs based on the leading content and format preferences voiced by older adult patients. The methodology adopted in the study can also be used for aligning the content and format of other patient education materials with patient preferences.

Surviving surgery; succumbing to pharmacotherapy: A case report underscoring the importance of PRN order clarification for patient safety

"Pro re nata" (PRN) or "as needed" medicine administration and usage is a relatively neglected area in medication management (pharmacotherapy/pharmaceutical care) which contributes to error-prone use of medications and is unsafe for patients. In this case, we report the incident of diclofenac toxicity in a 51-year-old woman due to a prescription of 100 mg diclofenac suppositories PRN, or as needed, for postoperative pain control without explanation of the maximum daily dose (150 mg daily), which led to arbitrary consumption of 3 g of diclofenac over 5 days (600 mg daily) by the patient, and subsequent development of metabolic acidosis, acute kidney injury, and sudden cardiac arrest. The implementation of practical guidelines and training programs for health care workers to appropriately prescribe, dispense, and administer PRN medicines are necessary, and should at least include providing clarification for their indication, dose and frequency, as well as any cautionary instructions to ensure safe and effective use of such medicines.

Documenting the indication for antimicrobial prescribing: a scoping review

BACKGROUND

Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice.

OBJECTIVES

We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations.

ELIGIBILITY CRITERIA

Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing.

SOURCES OF EVIDENCE

A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature.

CHARTING AND ANALYSIS

Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively.

RESULTS

We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice.

CONCLUSION

There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.

Incorporating 'reason for use' into the prescribing process of medication: a survey on the opinion of patients in Flanders, Belgium

Background

A longstanding debate exists about including a ‘reason for use’ on prescriptions for medication. Little is known, however, about patients’ opinions on this subject.

Methods

An internet-based questionnaire, consisting mainly of Likert scale questions, was distributed online to the general public in Belgium. Results from 1034 responses were analyzed using descriptive statistics.

Results

Opinions from patients toward including a ‘reason for use’ on medication prescriptions were generally positive. A clear majority of 62% increased to 74% after providing information about the possible link between indication and medication dose. A majority of the participants expressed a positive attitude regardless of the pathology involved, although sexually transmitted diseases were of greatest concern. Other important aspects differentiating the opinion positively was the transmission of this information in an electronic-only form and limiting it to the regular pharmacist excluding further use by third parties such as other pharmacies or insurance companies. Patients using multiple medicines and those frequenting the same pharmacy also had a more favorable opinion about including the reason for use. In addition, analysis of physician and pharmacist questionnaire responses, explicitly excluded from the main analysis, confirmed the known contrasting opinions in these subgroups.

Conclusions

Patients have strong support for transferring information on the ‘reason for use’ of their prescriptions to their regular pharmacy if this is done in a secure and privacy-conscious way enabling increased patient safety and improved pharmaceutical care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08596-w.

Evaluating Providers' Prescription Opioid Instructions to Pediatric Patients

Receiving an opioid prescription during childhood increases the risk of hazardous prescription opioid (PO) use during emerging adulthood. Instruction on how to safely use POs plays an essential role in pediatric patients’ capacity to utilize as well as to discontinue POs appropriately. This study aimed to evaluate pediatric PO label instructions provided to a large sample of pediatric outpatients. Data were extracted from the electronic healthcare records system identifying pediatric patients who received a PO between 2016 and 2019 from pediatric outpatient medical clinics were affiliated with a northwestern United States medical center and children’s hospital. Pediatric patients (n = 12,613) between 0−17 years old who received a PO during outpatient care were included. Patients with chronic health conditions (e.g., cancer) or who received their PO from an inpatient medical setting were excluded. Patient demographics, medication instructions, associated diagnoses, and other prescription information (e.g., name of medication, dose, and quantity dispensed) were examined using automated text classification. Many label instructions did not include any indication/reason for use (20.8%). Virtually none of the POs (>99%) included instructions for how to reduce/wean off POs, contact information for questions about the POs, and/or instructions around how to dispose of the POs. Efforts are needed to ensure that pediatric PO instructions contain essential elements to improve comprehension of when and how to use POs for pediatric patients.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

OBJECTIVES

Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are prescribed and administered to assisted living (AL) residents, overall and in relation to resident- and community-level characteristics.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

All AL residents and select staff in 250 AL communities in 7 states.

METHODS

Data regarding prescribing and administration of 5 types of PRN psychotropic medications in the prior 7 days (antipsychotics, mood stabilizers and antiepileptics, antidepressants, anxiolytics/hypnotics, and cognitive enhancers) were abstracted and compared across resident and community characteristics.

RESULTS

Prescribing of PRN psychotropics in AL is low (10.3%). Of prescribed PRN medications, 2.5% of residents were administered a PRN and 8% had PRN that was not administered in the previous 7 days. Anxiolytics were administered PRN more commonly compared with antipsychotics (2.0% vs 0.2%). Of all PRN psychotropic prescriptions (n = 1039), 70.5% had a written indication describing the reason for administration. Among PRN medications administered (n = 242), the proportion with an indication was lower (62.0%). PRN psychotropic medication prescribing was higher among residents with dementia and a psychiatric diagnosis, and in larger AL communities and those with a higher proportion of dementia care beds.

CONCLUSIONS AND IMPLICATIONS

The prescribing and administration of PRN psychotropic medications in AL is relatively rare, although more common among residents with dementia. Emerging psychotropic medication policies should be expanded to address mental health care, anxiolytic/hypnotic use for residents living with dementia, PRN prescribing in chart review, and the use of detailed indications for PRN use, especially when medications are administered by unlicensed care staff.

The use of narrative electronic prescribing instructions in pharmacoepidemiology: A scoping review for the International Society for Pharmacoepidemiology

Narrative electronic prescribing instructions (NEPIs) are text that convey information on the administration or co‐administration of a drug as directed by a prescriber. For researchers, NEPIs have the potential to advance our understanding of the risks and benefits of medications in populations; however, due to their unstructured nature, they are not often utilized. The goal of this scoping review was to evaluate how NEPIs are currently employed in research, identify opportunities and challenges for their broader application, and provide recommendations on their future use. The scoping review comprised a comprehensive literature review and a survey of key stakeholders. From the literature review, we identified 33 primary articles that described the use of NEPIs. The majority of articles (n = 19) identified issues with the quality of information in NEPIs compared with structured prescribing information; nine articles described the development of novel algorithms that performed well in extracting information from NEPIs, and five described the used of manual or simpler algorithms to extract prescribing information from NEPIs. A survey of 19 stakeholders indicated concerns for the quality of information in NEPIs and called for standardization of NEPIs to reduce data variability/errors. Nevertheless, stakeholders believed NEPIs present an opportunity to identify prescriber's intent for the prescription and to study temporal treatment patterns. In summary, NEPIs hold much promise for advancing the field of pharmacoepidemiology. Researchers should take advantage of addressing important questions that can be uniquely answered with NEPIs, but exercise caution when using this information and carefully consider the quality of the data.

Prescribers' perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis

BACKGROUND

The indication for prescribing a particular medication, or its reason for use (RFU) is a crucial piece of information for all those involved in the circle of care. Research has shown that sharing RFU information with physicians, pharmacists and patients improves patient safety and patient adherence, however RFU is rarely added on prescriptions by prescribers or on medication labels for patients to reference.

METHODS

Qualitative interviews were conducted with 20 prescribers in Southern Ontario, Canada, to learn prescribers' current attitudes on the addition of RFU on prescriptions and medication labels. A trained interviewer used a semi-structured interview guide for each interview. The interviews explored how the sharing of RFU information would impact prescribers' workflows and practices. Interviews were recorded, transcribed and thematically coded.

RESULTS

The analysis yielded four main themes: Current Practice, Future Practice, Changing Culture, and Collaboration. Most of the prescribers interviewed do not currently add RFU to prescriptions. Prescribers were open to sharing RFU with colleagues via a regional database but wanted the ability to provide context for the prescribed medication within the system. Many prescribers were wary of the impact of adding RFU on their workflow but felt it could save time by avoiding clarifying questions from pharmacists. Increased interprofessional collaboration, increased patient understanding of prescribed medications, avoiding guesswork when determining indications and decreased misinterpretation regarding RFU were cited by most prescribers as benefits to including RFU information.

CONCLUSIONS

Prescribers were generally open to sharing RFU and clearly identified the benefits to pharmacists and patients if added. Critically, they also identified benefits to their own practices. These results can be used to guide the implementation of future initiatives to promote the sharing of RFU in healthcare teams.

Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis

Objective

Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST).

Methods

To identify studies, the following databases were systematically searched on October 14^th, 2018 and repeated on September 12^th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review.

Results

Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I² = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I² = 36%).

Conclusion

This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.

PRN Medicines Optimization and Nurse Education

Medicines management is a high-risk and error prone process in healthcare settings, where nurses play an important role to preserve patient safety. In order to create a safe healthcare environment, nurses should recognize challenges that they face in this process, understand factors leading to medication errors, identify errors and systematically address them to prevent their future occurrence. ''Pro re nata'' (PRN, as needed) medicine administration is a relatively neglected area of medicines management in nursing practice, yet has a high potential for medication errors. Currently, the international literature indicates a lack of knowledge of both the competencies required for PRN medicines management and the optimum educational strategies to prepare students for PRN medicines management. To address this deficiency in the literature, the authors have presented a discussion on nurses' roles in medication safety and the significance and purpose of PRN medications, and suggest a model for preparing nursing students in safe PRN medicines management. The discussion takes into account patient participation and nurse competencies required to safeguard PRN medication practice, providing a background for further research on how to improve the safety of PRN medicines management in clinical practice.

Work effort, readability and quality of pharmacy transcription of patient directions from electronic prescriptions: a retrospective observational cohort analysis

Background

Free-text directions generated by prescribers in electronic prescriptions can be difficult for patients to understand due to their variability, complexity and ambiguity. Pharmacy staff are responsible for transcribing these directions so that patients can take their medication as prescribed. However, little is known about the quality of these transcribed directions received by patients.

Methods

A retrospective observational analysis of 529 990 e-prescription directions processed at a mail-order pharmacy in the USA. We measured pharmacy staff editing of directions using string edit distance and execution time using the Keystroke-Level Model. Using the New Dale-Chall (NDC) readability formula, we calculated NDC cloze scores of the patient directions before and after transcription. We also evaluated the quality of directions (eg, included a dose, dose unit, frequency of administration) before and after transcription with a random sample of 966 patient directions.

Results

Pharmacy staff edited 83.8% of all e-prescription directions received with a median edit distance of 18 per e-prescription. We estimated a median of 6.64 s of transcribing each e-prescription. The median NDC score increased by 68.6% after transcription (26.12 vs 44.03, p<0.001), which indicated a significant readability improvement. In our sample, 51.4% of patient directions on e-prescriptions contained at least one pre-defined direction quality issue. Pharmacy staff corrected 79.5% of the quality issues.

Conclusion

Pharmacy staff put significant effort into transcribing e-prescription directions. Manual transcription removed the majority of quality issues; however, pharmacy staff still miss or introduce following their manual transcription processes. The development of tools and techniques such as a comprehensive set of structured direction components or machine learning–based natural language processing techniques may help produce clear directions.