Hindawi

BioMed Research International

Volume 2020, Article ID 8842515, 7 pages
https://doi.org/10.1155/2020/8842515

Research Article
Assessment of Prescription Completeness and Drug Use Pattern in
Tibebe-Ghion Comprehensive Specialized Hospital, Bahir
Dar, Ethiopia

Zewdu Yilma , Tena Mekonnen , Ebrahim Abdela Siraj , Zegaye Agmassie,

Adane Yehualaw , Zenaw Debasu , Chernet Tafere, and Misgan Ararsie
Department of Pharmacy, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, P.O. Box 79, Ethiopia

Correspondence should be addressed to Zewdu Yilma; ziedo21@gmail.com

Received 12 September 2020; Revised 29 September 2020; Accepted 13 October 2020; Published 20 October 2020

Academic Editor: Nahide Gulsah Deniz

Copyright © 2020 Zewdu Yilma et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction. Irrational medicine use is a global problem, and one of its manifestation is inappropriate prescribing that occurs when
medicines are not prescribed in accordance with the guideline. Objective. The aim of the study was to assess prescription
completeness and drug use pattern of the hospital using the WHO core drug use indicators. Methods. 1000 prescriptions were
collected retrospectively from prescriptions written for 1 year from outpatient pharmacies of the hospital. Exit interview was
employed to assess patient care indicators. The health facility indicators were checked by assessing the presence of drug
formulary and availability of key medicines at the facility. Data were analyzed using SPSS version 20. Results. It was found that
only name of the patients was filled in all the prescriptions. Other informations were below the standard. The average number
of drugs per prescription was 1.65. Percentages of encounter by generic name, with antibiotic and injections, were 85.78%, 41%,
and 25%, respectively. The percentage of drugs prescribed from an essential drug list was 98.48%. The mean consultation time
and dispensing time were 14.49 and 2.16 minutes, respectively. More than half patients had knowledge on drug dispensed to
them (68%). The percentage of drugs actually dispensed was 65%, but none of the drugs dispensed were adequately labelled. A
copy of EDL and 84% of the key drugs were available in the hospital. Conclusion. From the results of our study, it can be
concluded that all prescriptions were not complete, and except the average number of drugs prescribed per encounter, the other
drug use pattern indicators were out of the WHO recommendation. Therefore, effective intervention program, like training, for
promotion of rational drug use practice was recommended.

1. Introduction ical care, raise health care costs, and may cause adverse reac-
tion, as well as being a primary contributor to the spread of
Medicines are substances or a mixture of substances used for antimicrobial resistance [2].
prevention, diagnosis, mitigation, or treatment of disease [1]. Medicine use is a complex activity involving the interac-
Most leading cause of death and disability in developing tion of different bodies like health professionals, the patient
countries can be prevented, treated, or at least alleviated with (client), and health institutions. All involved in the therapeu-
cost effective essential medicines. Despite this fact, hundreds tic process contribute to irrational use in a variety of ways [3].
of millions of people do not have regular access of these Inappropriate prescribing is one of the manifestation of irra-
medicines, and many of those who have access are using it tional medicine use that occurs when medicines are not pre-
irrationally. Irrational medicine use occurs with polyphar- scribed in accordance with the guideline. All the necessary
macy, with the use of wrong or ineffective medicine, or with information in the prescription should be completed by the
under use or incorrect use of effective medicine. These prescribers, since incomplete information could lead to poor
actions negatively affect the quality of drug therapy and med- treatment outcome and be harmful to the patient. In order to
2 BioMed Research International

say a given prescription paper is complete, all parameters that and April 1, 2020. Patient care indicators were assessed pro-
are indicated in the prescription paper have to be completed spectively by conducting exit interview for 100 patients at the
by the prescribers [2, 4]. outpatient pharmacy of TGCSH between April and May
In order to design different interventional strategies 2020. Health facilities were assessed through observation in
attempting to change medicine use, the scale of the problem order to assess the availability of drug formulary and key
should be assessed and quantified. Drug utilization research medicines at the facility during study period.
with the WHO drug use indicators is becoming increasingly Patients included for patent care indicator study were
necessary to promote rational medicine use and to identify those who attend in outpatient pharmacy and willing to par-
problems related to medicine use especially in developing ticipate. Those who were severely ill, unable to talk, and who
countries, like Ethiopia, to ensure that the scarce resources were not willing to participate were excluded from this study.
are utilized in the best possible manner. Conducting periodic All the three groups of indicators were assessed based on the
studies of pattern of drug use in various hospital settings or WHO/International Networks for Rational Use of Medicines
patient populations is essential to identify specific medicine (INRUD) guidelines [3].
use problems, sensitize practitioners on rational medicine To assess the availability of key medicines in the hospital,
prescription, and to critically analyze the current hospital 25 medicines were included according to modified Federal
drug policies and to make recommendations based on vari- Ministry of Health tracer Medicines list [12].
ous guidelines to improve upon the current drug usage pat-
tern [5, 6]. 2.3. Data Collection and Analysis. Statistical Packages for
Studies done in Alexandria (Egypt) [7], India [8], Jordan Social Sciences (SPSS) version 20 was employed for entry
[9], and selected public hospitals of eastern Ethiopia [10], as and analysis of the quantitative data. In the statistical analy-
an example, showed that most of the WHO drug utilization sis, frequencies and percentages were obtained. The findings
core indicators were below the optimum value. This indicates were interpreted according to standard values of WHO pre-
that periodic assessment and intervention is necessary in scribing indicators [3].
every health settings in order to have and maintain the use
2.4. Ethical Approval. A support letter was obtained from
of drugs rationally.
College of Medicine and Health Science before conducting
The current study was, therefore, designed to identify the
the study. TGCSH Pharmacy Service Directorate gave per-
major problems in prescription completeness and rational
mission to undertake the study. Consent of each participants
use of drugs in Tibebe-Ghion comprehensive specialized
of the study was taken before they were interviewed. Individ-
hospital, by using WHO indicators. This investigation plays
uals participating in the study were informed about the pur-
a major role to prioritize the main intervention areas regard-
pose of the study. Study participants with inadequate
ing rational use of medicines. It might provide baseline infor-
knowledge were advised on how to take their medicine prop-
mation for researchers who are interested to conduct further
erly after the interview.
studies to determine factors for drug use pattern in this
facility.
3. Results
2. Methods 3.1. Prescription Completeness. In order to assess the pre-
scription completeness, patient related, treatment related,
2.1. Study Area and Period. The study was conducted in prescriber related, and dispenser related information were
Tibebe-Ghion comprehensive specialized hospital, a teaching considered. Principally, each information in the prescription
hospital under college of medicine and health sciences of should be filled. In this study, it was found that only full name
Bahir Dar University located in Bahir Dar, Ethiopia. The of the patient was filled in all the prescription seen. The
Pharmacy Service Directorate is one of the seven directorates recordings with respect to patient weight, address of the
found in the hospital. The study was conducted from April to patient, and dosage form of the drug were below 10%. Except
May 2020. dosage form and total drug dose, other parameters with
regard to treatment information were above 61%. From pro-
2.2. Study Design. Institutional based cross-sectional study fessional information, relatively better practice was found in
design was used to collect the quantitative data from pre- prescribers than dispensers (Table 1).
scription papers dispensed to outpatients between April 1,
2019, and April 1, 2020 (1 year). Prescriptions which con- 3.2. Prescribing Indicators. One thousand prescriptions were
tained only drugs and drugs with medical supplies and dis- analyzed, and a total of 1650 prescribed drug products were
pensed to outpatients were included in this study. However, obtained. The average number of drugs per prescription
the investigation excluded inpatient prescriptions, prescrip- was 1.65. The total number of drugs prescribed by generic
tions with only medical supplies, fluids, and/or parenteral name was 1415 (85.78%). Antibiotics were prescribed in
nutrition. According to the WHO guide, at least 600 encoun- 410 (41%) encounters, and injections were prescribed in
ters should be included in a cross-sectional survey to describe 250 (25%) prescriptions. 1625 (98.48%) drugs prescribed
the current prescribing practices, with a greater number if were from essential drug list (Table 2).
possible [11]. Therefore, prescribing indicators were assessed Out of 1650 drugs prescribed, 445 (26.97%) were antibi-
retrospectively using 1000 prescriptions selected by ran- otics. The three most commonly prescribed antibiotics were
domly among prescriptions filled between April 1, 2019, ciprofloxacin 83 (18.65%), ceftriaxone 82 (18.43%), and
BioMed Research International 3

Table 1: Prescription completeness assessment at Tibebe-Ghion comprehensive specialized hospital from April 2019 to April 2020 (n = 1000).

Professional information
Patient information Treatment information
S/N Prescribers Dispensers
Parameters % Parameters % Parameters % Parameters %
1 Full name 100.0 Drug name 99.5 Full name 88.5 Full name 55.4
2 Sex 99.4 Drug strength 67.5 Qualification 49.3 Qualification 11.2
3 Age 98.8 Drug dose 61.3 Date 89.4 Date 40.1
4 Weight 0.4 Total drug dose 37.3 Signature 95.5 Signature 78.7
5 Card # 99.1 Frequency 87.8
6 Diagnosis 31.0 Duration 75.3
7 Address of the patient 1.9 Dosage form 8.3

Table 2: Drug prescribing indicators at Tibebe-Ghion comprehensive specialized hospital from April 2019 to April 2020 (n = 1000).

Prescribing indicators Number Average/percentage Ideal WHO value [7]

Average number of drugs per encounter 1650 1.65 1.6-1.8
Percentage of drugs prescribed by generic 1415 85.78% 100%
Percentage of encounter with antibiotics 410 41.00% 20.0-26.8%
Percentage of encounter with injections 250 25.00% 13.4-24.1%
Percentage for drugs from essential drug list 1625 98.48% 100%

metronidazole 50 (11.24%) (Table 3). Of the total drugs pre- dispenser’s full name, qualification and signature, date of
scribed, 515 (30.28%) were in the form of injections. The first prescribing and dispensing) [5, 13].
three most commonly prescribed injections were ceftriaxone It is recommended that any prescriber and dispenser
82 (17.67%), diclofenac 45 (9.70%), and metronidazole 30 should fill/record the required information (i.e., patient,
(6.47) (Table 4). treatment, and professionals’ information) on the prescrip-
tion paper. But in this study, except the name of the patient,
3.3. Patient Care Indicators. One hundred patients were con- all the assessed prescriptions were incomplete which con-
sidered to analyze patient care indicators and found that an tained at least one or more unfilled parameters. If we look
average of 14.49 minutes was taken to consult the patient at the patient information, only 0.4%, 1.9%, and 31% of pre-
and 2.16 minutes for dispensing the prescribed drugs to the scriptions had weight, address, and diagnosis of the patient,
patient. Out of the total 200 drugs prescribed, only 130 respectively. The other patient-related information were
(65%) were actually dispensed with no adequate labeling. above 98%. Out of the treatment information, the least
Of the patients interviewed, 68 (68%) had knowledge on records were found for dosage form type (8.3%) and total
the correct dose (Table 5). drug dose (37.3%). The remaining treatment-related infor-
mation were found 61% and above. With regard to the pro-
3.4. Facility Specific Indicators. In the hospital pharmacy, the fessionals’ information, though the recordings were below
essential drug list is available, and there are 25 drugs which the required (100%), prescribers’ information were well
are considered as key drugs. During the study period, only recorded relative to the dispensers’ information (Table 1).
21 drugs (84%) were available (Table 6). Although there were poor practices that has to be corrected,
compared to other studies done elsewhere [5, 13], our study
4. Discussion revealed the presence of relatively better practice in the hos-
pital in almost all prescription information parameters.
4.1. Prescription Completeness. Prescription order is an
important transaction between the physician and the patient. 4.2. Prescribing Indicators. Inappropriate use of drugs occurs
Therefore, it should be written legibly, accurately, and all over the world and causes harm to people [7]. In our
completely in order to minimize errors in the dispensing study, WHO/INRUD drug use indicators were used to
and administration of medications. In order to say the pre- describe current treatment practices that are helpful for prob-
scription paper is complete, all parameters that are indicated lem identification, detect whether a facility is exceeding or
in the prescription paper have to be completed by the pre- under a set norm of practice [3], and serve as a baseline infor-
scribers. These are patient information (patient full name, mation for continuous monitoring for ongoing basis in the
sex, age, weight, card number), treatment information hospital.
(medicine full name in generic, strength, dosage form, dose, In the current study, the average number of drugs per
frequency, duration of treatment), and professionals’ infor- encounter was 1.65, which is within the recommended limit
mation (prescriber’s full name, qualification and signature, by the WHO/INURD [11]. Compared to other studies
4 BioMed Research International

Table 3: Commonly prescribed antibiotics at Tibebe-Ghion Table 4: Commonly prescribed injections at Tibebe-Ghion
comprehensive specialized hospital from April 2019 to April 2020 comprehensive specialized hospital from April 2019 to April 2020
(n = 1000). (n = 1000).

Prescribed antibiotics Frequency of Percentage Prescribed injection Frequency Percentage

Ciprofloxacin 83 18.65 Ceftriaxone 82 17.67
Ceftriaxone 82 18.43 Diclofenac 45 9.70
Metronidazole 50 11.24 Metronidazole 30 6.47
Amoxicillin 29 6.52 Tramadol 29 6.25
Azithromycin 29 6.52 Insulin NPH 23 4.96
Amoxicillin with clavulanic acid 28 6.29 Cloxacillin 19 4.09
Cephalexin 24 5.39 Lidocaine 18 3.88
TTC eye ointment 19 4.27 Dextrose 40% glucose 16 3.45
Cloxacillin 16 3.60 Vancomycin 13 2.80
Vancomycin 14 3.15 Dexamethasone 12 2.59
Ampicillin 9 2.02 Ranitidine 12 2.59
Gentamicin 9 2.02 Atropine 11 2.37
Doxycycline 8 1.80 Tetanus antitoxin 11 2.37
Cefixime 7 1.57 Ampicillin 9 1.94
B. penicillin 6 1.35 Cimetidine 9 1.94
Oxytetracycline 6 1.35 D5%W 9 1.94
Griseofulvin 5 1.12 Gentamycin 9 1.94
Cefepime 4 0.90 Oxytocin 9 1.94
Chloramphenicol 4 0.90 Ciprofloxacin 8 1.72
Hydrogen peroxide 4 0.90 Heparin 8 1.72
Norfloxacine 3 0.67 Metoclopramide 8 1.72
Aciclovir 1 0.22 Omeprazole 7 1.51
Ceftazidime 1 0.22 Regular insulin 7 1.51
Clarithromycin 1 0.22 Ringer lactate 7 1.51
Clotrimazole 1 0.22 B. penicillin 6 1.29
Erythromycin 1 0.22 Pethidine 6 1.29
Nitrofurantoin 1 0.22 Furosemide 5 1.08
Total 445 100 Diazepam 4 0.86
Hydrogen peroxide 4 0.86
conducted in Ethiopia, like Ayder referral hospital (2.61) Mannitol 4 0.86
[14], Debremarkos Hospital (2.4) [15], five national regional Haloperidol 3 0.65
states (Tigray, Amhara, Oromia, SNNPR, Benishangul- Hydrocortisone 3 0.65
Gummuz), and Addis Ababa (1.99) [16], and abroad like Hyoscine 3 0.65
Kenya 2.7 [17], Nigeria 3.04 [18], India 3.11 [19], Ghana KCl 3 0.65
4.8 [20], Bahrain 3.3 [21], and United Arab Emirates
Adrenaline 2 0.43
(UAE) 2.49 [22], the presented study showed better prescrib-
ing practice regarding the number of drugs per prescription. Cefepime 2 0.43
Low generic prescribing practice is observed in our study; Dextrose in normal saline 2 0.43
out of 1650 drugs, only 1415 (85.78%) drugs were prescribed Artesunate 1 0.22
with their generic name. This value is lower than that of the Bupivacaine 1 0.22
WHO recommendation (100%) [11]. Higher values were Ceftazidime 1 0.22
obtained from studies conducted in Hawassa University Magnesium sulphate 1 0.22
teaching and referral hospital 98.7% [23], Felege Hiwot refer-
Potassium chloride 1 0.22
ral hospital 97.4% [24], and Ayder referral hospital 93.3%
[14]. However, our study revealed relatively better prescrib- Vitamin B complex 1 0.22
ing practice than from studies done in Debremarkos Hospital Total 464 100
77.7% [15], four west Ethiopia public hospitals (Ambo, Gedo,
Nekemet, Gimbi) 79.2% [25] and Borumeda hospital 80.02%
[26]. Some studies conducted abroad showed much smaller
generic prescribing practice than from the current study,
BioMed Research International 5

Table 5: Patient care indicators at Tibebe-Ghion comprehensive 4.3. Patient Care Indicators. The time spend by prescribers
specialized hospital from April 2019 to April 2020 (n = 100). and dispensers with each patient sets important limits on
the potential quality of diagnosis and treatment. Patients
Patient care indicators Values for whom drugs are prescribed should, at a minimum, receive
% consultation time 14.49 min well-labeled medications and should understand how to take
% dispensing time 2.16 min each drug.
% drugs actually dispensed 65% In our study, the average time that the patient spent with
% drugs adequately labeled 0% the prescriber was about 15 minutes. This consultation time
Patients’ knowledge of correct dose 68%
is better than from other studies done elsewhere, Pakistan
(22 min) [27], Egypt (7.1 min) [7], and selected hospitals in
eastern Ethiopia (4.61 min) [10], but lower than a study done
for example, in Kenya 45.5% [17], Nigeria 42.7% [18], Paki- in Malaysia (18.2 min) [34]. Slower and longer consultation
stan 71.6% [27], Nepal 59.02% [28], Jordan 57.6% [29], and is associated with doctors being more likely to identify psy-
Uzbekistan 38% [30]. But generic use in India 96.88% [19] chosocial problems, explore presenting complaints more
and UAE 100% [22] was higher. accurately, prescribe less, and offer more preventative advice
Overuse of antibiotics is not recommended in any health [34].
facility or community, because it develops resistance, which Time spent with the dispenser was found to be 192.6 secs
is called antimicrobial resistance [31]. In the current study, which can be considered very enough compared to other
antibiotics were prescribed in 410 (41%) of the total prescrip- studies done in selected public hospitals in eastern Ethiopia
tions which is higher to WHO recommendation (20-26.8%) (61.12 sec) [10], Pakistan (38 sec) [27], and Egypt (47.4 sec)
[11]. Higher values were also found in studies conducted at [7]. Comparable, even better, result was reported in private
Debremarkos Referral Hospital (71.36%) [15], Hawassa Uni- tertiary care teaching hospital in India (244 sec) [35].
versity teaching and referral hospital (58.1%) [23], five In order to measure the degree to which the hospital is
national regional states (Tigray, Amhara, Oromia, SNNPR, able to provide the drugs which is prescribed, the dispensers
and Benishangul-Gummuz) and Addis Ababa (58%) [16], record essential information on the drug packages they dis-
and four west Ethiopia public hospitals (Ambo, Gedo, Neke- pense and to measure the effectiveness of the information
met, Gimbi) (54.7%) [25]. However, compared to our study, given to patients on the dosage schedule of the drugs they
lower values were seen in Felege Hiwot hospital 38% [24], receive; percentage of drugs actually dispensed, adequately
Borumeda hospital 34.57% [26], and Ayder referral hospital labelled, and patients’ knowledge of correct dose were stud-
32% [14]. Studies done in Kenya, Ghana, Bahrain, and Paki- ied. The percentage of drugs actually dispensed was 65%.
stan had resulted values of 74%, 60%, 45.8%, and 48.9%, This value is less than from what is ideally recommended
respectively [17, 20, 21, 32]. In the contrary, better results (i.e., 100%) and from studies done in Pakistan (90.9%) [27],
which were within the limit of WHO recommendation were Egypt (95.9%) [7], and private tertiary care teaching hospital
found in studies conducted at an Indian hospital, in health in India (95.5%) [35]. In our study, it was found that no drug
facilities of Jordan and UAE with values of 22.19%, 17.7%, was adequately labelled (0%). This was due to inadequate
and 9.8%, respectively [19, 22, 29]. availability of the packaging materials in the studied health
Irrational use of injections is the means for transmission facility. Due to this, only oral information had been given
of very serious blood-borne infections and leads to morbid- to the patients. The percentage of patients’ knowledge of cor-
ity and death. In the current study, injections were pre- rect dose was studied and resulted 68%, which was higher
scribed in 250 (25%) of the total prescriptions. This value than a study in private tertiary care teaching hospital in India
is close to, but a bit higher, the WHO recommendation (31%) [35] and comparable to the value found in Pakistan
(13.4-24.1) [11]. A study done in Debremarkos referral (62.1%) [27] but less than those of results obtained from
hospital showed that 48.36% prescriptions had injectable studies in selected hospitals in eastern Ethiopia (75.7%)
[15], 42.2% was found in Mekelle General Hospital [33], [10] and Egypt (94%) [7].
and 38.1% was revealed in Hawassa University teaching
and referral hospital [23]. 4.4. Facility-Specific Indicators. Our study revealed that the
An essential medicine list is one of the key tools for hospital had a copy of EDL/formulary which is in agreement
applying rational drug use, and use of such a list for any with the recommended value (optimal value 100%). The
community-based health-care program has a major role in availability of these materials is vital for health professionals
the effectiveness of therapy [8]. In our study, out of the total for continuous professional improvement and good patient
prescribed drugs, 98.48% of drugs were listed in the hospital’s outcomes. The problem was not yet distributed to health pro-
essential drug list. This result is less than from the recom- fessionals. Similar result was obtained in study conducted at
mended value by WHO (100%) and other study reports from Tikur Anbesa Specialized Hospital [5]. On the other hand,
different health facilities in Ethiopia, like Felege Hiwot refer- the percentage of key drugs in the stock was 84%. This value
ral hospital and Ayder referral hospital which adhered 100% was better than a finding from selected public hospitals in
with EML [14, 24] but comparable to the studies done in eastern Ethiopia (66.7%) [10] and Egypt (78.3%) [7] and
Debremarkos referral hospital and Hawassa University lower than that of a study in private tertiary care teaching
teaching and referral hospital, whose results were 98.24% hospital in India (91.6%) [35] and that of the recommended
and 96.6%, respectively [15, 23]. value (100%), but it was in concord with a study in Pakistan
6 BioMed Research International

Table 6: Facility specific indicators at Tibebe-Ghion comprehensive specialized hospital from April 2019 to April 2020.

Facility specific indicators Availability in the hospital Distributed to the staff (Y/N)
Availability of copy of EDL or formulary Available No
% availability of key drugs in the stock 84% No
Y/N = Yes/No.

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