Kathmandu University Medical Journal (2006), Vol. 4, No.

4, Issue 16, 436-443

Original Article
A study on rational drug prescribing and dispensing in outpatients
in a tertiary care teaching hospital of Western Nepal
Alam K1, Mishra P2, Prabhu M3, Shankar PR4, Palaian S5, Bhandari RB6, Bista D7
1,6,7
Hospital Pharmacist, 2,4Assistant Professor, 3Associate Professor, 5Lecturer, Manipal Teaching Hospital, Manipal
College of Medical Sciences Pokhara, Nepal

Abstract
Objectives: To analyze the prescriptions of out-patients for rational prescribing and dispensing and to evaluate the
patient’s knowledge regarding use of drugs, using INRUD indicators.
Methods: A cross-sectional, descriptive study was conducted at the Manipal Teaching Hospital, Pokhara, Nepal
during the time period from June 10th to August 19th 2004.
Results: Totally 247 prescriptions were randomly selected for analysis, wherein 720 drugs were prescribed. Only
15% of drugs were prescribed by generic name, 21.67% of the total drugs consisted of fixed-dose combinations,
only 40% of drugs were from the Essential drug list of Nepal and 29.44% (n=212) were from the WHO Essential
drug list. It was found that more than half (54.17 %) of the drugs were from Nepalese National Formulary and
35.69% were from WHO model formulary. Dermatological products were most commonly prescribed followed by
drugs acting on central nervous system, antimicrobials and drugs acting on cardiovascular system. Among the drugs
dispensed, 79.16% were oral followed by topical (18.19%) and parenteral forms (2.98%). Diagnosis was mentioned
only in 3.23% (n=8) of the prescriptions and the average cost per prescription was found to be 241.11 Nepalese
rupees (US$ 3.26). It was found out that pharmacist labelled only 0.4% of the medication envelopes with the name
of the patient. However, 82.6% of the medication envelopes were labelled with name of the drug and 87.0 % with
drug strength. Only 53.8% (n=133) of the patient knew both the duration of the therapy and administration time of
drugs.
Conclusion: There is a need for educational intervention for prescribers and both managerial and educational
intervention for the hospital pharmacists to improve prescribing and dispensing.

Key words: Rational use of drugs, Dispensing, Pharmacist, Prescribing

I t is well documented that safe and effective drug

therapy most is possibly only when patients are
well informed about the medications and their use1.
prescribed dosage and quantity, with clear
instructions on its appropriate use. Competent and
qualified pharmacists should be trained for
Every member of the healthcare team should practice dispensing and for giving clear/proper instructions to
rational drug therapy. Rational drug use means the patient on safe and effective use of drugs. The
patients receive medications appropriate to their pharmacists should have an easy access to complete
clinical needs, in doses that meet their own individual and unbiased information on the drugs used and
requirements, for an adequate period of time and at should undergo prerequisite training programs. The
the lowest cost to them and their community.2 Omnibus Budget Reconciliation Act-1990 (OBRA-
Confusion over brand names, overwhelming 90) and Society of Hospital Pharmacists of Australia
workload of doctors and pharmacists, cost factor, (SHPA) have established the minimum standards for
patient attitudes, erratic supply of drugs, lack of information to be given to the patients by the
institutional formulary etc can lead to irrational use dispensing pharmacists4,5.
of drugs. Irrational drug use can lead to reduction in
quality of drug therapy, increased risk of unwanted
effects, drug resistance etc. The five important
criteria for rational drug use are accurate diagnosis, Correspondence
Kadir Alam
proper prescribing, correct dispensing, suitable Hospital Pharmacist
packing and patient adherence3. The prescribers Department of Pharmacy, Manipal Teaching Hospital, Manipal
should make an accurate diagnosis and prescribe College of Medical Sciences
rationally and the pharmacist should ensure that Pokhara, Nepal.
Email: [email protected]
effective form of the drug reaches the right patient in

436
The pharmacist is often the last member of the health of the prescriptions and patient knowledge on proper
care team to see the patient before he/she takes the use of drugs as per the INRUD indicator. The
drug and has an immense responsibility in average number of drugs per prescription and the
counselling the patients6. Concept of rational use of patient knowledge of use of drugs were compared
drug is new in developing countries like Nepal, among different departments. Mann-Whitney U test
though several steps have been taken in the recent was used for dichotomous variables and Kruskal-
past towards ensuring rational drug use. Among the Wallis test for the others. A p-value less than 0.05
various measures, the development and revision of was taken as statistically significant.
National essential drug list, development of National
Formulary, amending pharmacy act and opening drug Results
information centres are vital. The periodic evaluation Totally, 247 encounters were documented, in which a
of prescriptions can be a good tool to evaluate the total of 720 drugs were prescribed. The mean ± SD
rational use of drugs in terms of prescribing and number of drugs prescribed was 2.91 ± 1.41 out of
dispensing and to evaluate patient understanding them 706 (98.05%) were dispensed from the hospital
regarding drug usage. We conducted the study with pharmacy. The remaining drugs were either not
the following objectives: available in the pharmacy or the patients had the
drugs in their home or the patients did not have
1. To analyze the prescriptions for rational enough money to buy them.
prescribing and dispensing,
2. To evaluate the patient’s knowledge More than 1/5th [21.67%, (n=156)] of the total drugs
regarding use of drugs; as per the prescribed were fixed dose combinations (FDCs), and
International Network for Rational Use of only 15% of the drugs (n=108) were prescribed by
Drugs (INRUD) indicators. generic name, 40 % (n=288) of drugs were from the
Essential drug list of Nepal and 29.44% (n=212) were
Materials and methods from WHO essential drug list. It was found that
Settings 54.17 % (n= 390) of the drugs were from Nepalese
The study was conducted at the out patient pharmacy National Formulary and 35.69% (n=257) were from
of the Manipal Teaching Hospital, Pokhara, Nepal, a WHO model formulary.
550-bedded tertiary care teaching hospital. The data
for this study was collected over the time period from Gender analysis revealed that female patients were
June 10th to August 19th 2004 (10 weeks). Patients slightly more in number (49.8%) compared to males
visiting the out patient pharmacy with a prescription (46.6%). In 3.2% of prescriptions sex was not
from the hospital OPD were randomly enrolled in the mentioned. With regard to age 23.5% patients were
study. in the age group of 21-30 Years while 18.2% patients
were in the age group 31-40 years. Table 1 shows the
Questionnaire and interview details of the age distribution.
The INRUD encounter form (Appendix 1) was used
for the study. The patients and their prescriptions In relation to various departments, 71 (28.7) were
were used as source of data. The prescription and from the Department of Medicine followed by
labelling of the dispensed drugs were checked for Dermatology (13.8%). The details are listed in Table
their accuracy and all the relevant data were entered 2.
in the encounter form. The patients were also
interviewed for their knowledge regarding dose, The average number of drugs per prescription was
duration, and frequency of the drugs to be taken after found to be higher in psychiatry department and least
the drugs were dispensed. In case of paediatric in orthopaedics department. The details are displayed
patients and patients with mental illness, patient party in Table 3.
was interviewed as the patients themselves may not
be able to communicate well. Out of 720 prescribed drugs, it was found that 17.2%
of drugs were dermatological and topical products
Analysis followed by Central Nervous System (CNS) drugs
The filled encounter forms were analyzed for the age (14%), antimicrobials (12.1%) Cardiovascular system
distribution of patients, department wise (CVS) drugs, renal and drugs acting on blood
categorization of prescriptions, average number of (11.7%). The details are shown in Table 4. The cost
drugs per prescription, therapeutic category of drugs of the prescription was also assessed in the study and
prescribed, encounters with an antibiotic prescribed, is listed in Table 7. The average cost per prescription
encounters with at least one injectable, cost analysis was found to be NRs 241.11 (US$ 3.26).

437
Among the 247 encounters, an antimicrobial was envelope has a provision for patient name, name of
prescribed in 72 encounters (29.1%). The department the drug and instructions for taking the medicines. In
wise break-up of encounters with an antibiotic this study it was found that only 3 (0.4%) of the
prescribed is shown in Table 5. In the ENT drugs had the patient name labelled on the envelope
department an antimicrobial was prescribed in 2/3rd while 595 (82.6%) of the drugs had the drugs name
(66.77%) of encounters. and 633 (87.9%) had the administration time only
labelled on the envelope.
With regard to dosage forms, it was found that
majority of drugs prescribed were oral [570 (79.2%)] On interviewing the patients, it was found only 133
followed by topical [131 (18.2%)] and parenteral [15 (53.8%) of the patients/patient party knew both the
(2.1%)]. others 2 (0.3%). The use of injectables was time of administration and quantity of drugs to be
found to be highest in OBG department with at least taken. Moreover there was no significant difference
one injectable in 26.7 % of the prescriptions. between male and female patients and patients
belonging different age groups with regard to their
The pharmacy at Manipal Teaching Hospital utilizes knowledge of correct use of drugs. The patient
an envelope system to dispense the medicines. The knowledge regarding proper use of drugs is displayed
patients are provided with an envelope for every in the Table 8.
individual drug purchased from the pharmacy. The

Table 1: Age distribution of patients

Age group (Yrs) Number Percentage
Less than 10 21 8.5
11-20 30 12.1
21-30 58 23.5
31-40 45 18.2
41-50 31 12.6
51-60 14 5.7
61-70 27 10.9
> 70 13 5.3
Not mentioned 8 3.2

Table 2: Department wise categorization of prescriptions

Departments No. of prescription Percentage
Medicine 71 28.7
Dermatology 34 13.8
ENT 30 12.1
Psychiatry 27 10.9
OBG 15 6.1
Ophthalmology 15 6.1
Orthopaedics 13 5.3
Others (Paediatrics, oncology, dental, 42
surgery and emergency) 17

438
Table 3: Average number of drugs per prescription
Departments Total number of drugs Average drugs per
prescription
Medicine 225 3.2
Dermatology 87 2.6 *
ENT 86 2.9
Psychiatry 91 3.4>
OBG 51 3.4 **
Ophthalmology 36 2.4>>
Orthopaedics 21 1.6 ß
Others (Paediatrics, oncology, dental, surgery, 123 2.9
emergency, unidentified departments)
*p=0.001 compared to orthopaedics > p=0.051 compared to other departments
** p=0.004 compared to other departments >>p= 0.036 compared to orthopaedics
ß p=0.013 compared to other departments

Table 4: Therapeutic category of drugs prescribed

Therapeutic classification No. of drugs (%) Percentage
Dermatological and other topical agents 124 17.2
Central nervous system 101 14
Antimicrobials 87 12.1
Cardiovascular, renal and blood 84 11.7
Antihistamines 74 10.3
Analgesics and anti-inflammatory 54 7.5
Vitamins, minerals and dietary supplements 53 7.4
Gastrointestinal system 48 6.7
Respiratory system 27 3.8
Anti diabetics 20 2.8
Hormone and Hormone antagonist 13 1.8
Autonomic nervous system 11 1.5
Anti-parasites 3 0.4
Others 20
2.8

Table 5: Encounters with an antibiotic prescribed (n=72)

Departments Number Percentage
Medicine 12 16.9
Dermatology 12 35.3
ENT 20 66.7
Psychiatry 2 7.4
OBG 9 60.0
Ophthalmology 1 6.7
Orthopaedics 1 7.7
Others (Paediatrics, oncology, 15
dental, surgery and emergency) 35.7

439
Table 6: Injectable encounters (n=15)
Departments Number Percentage
Medicine 7 9.9
Dermatology 0 0.0
ENT 2 6.7
Psychiatry 0 0.0
OBG 4 26.7
Ophthalmology 0 0.0
Orthopaedics 0 0.0
Others (Paediatrics, oncology, 2
dental, surgery and emergency) 4.8

Table 7: Cost analysis

Cost (NRS) Number of prescriptions Percentage
0-100 69 27.94
101-200 75 30.36
201-300 42 17.00
301-400 23 9.31
401-500 12 4.86
500 -600 11 4.45
>600 15 6.07

Table 8: Patient knowledge on proper use of drugs

Departments No. of patients Percentage
Medicine 42 59.2
Dermatology 26 *, ** 76.5
ENT 12 > 40.0
Psychiatry 12>> 44.4
OBG 9ß 60.0
Ophthalmology 12 ß ß 80.0
Orthopaedics 9 69.2
Others (Paediatrics, oncology, dental, 11 26.2
surgery, emergency and unidentified
departments)
** p= 0.018 compared to Psychiatry * p= 0.005 compared to ENT
> p= 0.046 compared to Ophthalmology >>p= 0.028 compared to Ophthalmology
ß p= 0.003 compared to other departments ß ß p= 0.001 compared to others

Discussion
Prescribing pattern of drugs reflects the clinical Committee on Prevention, Detection, Evaluation, and
judgment of the clinicians. The average number of Treatment of High Blood Pressure (JNC-VII)
drugs per prescription was found to be 2.91 in our guidelines also permit polypharmacy in
study which is less than that reported from studies hypertension11.
conducted in Brazil (8.6), Ghana (3.6) and West
Bengal, India (3.2)7,8,9. Lesser number of drugs is a Our study reports that 21.67% of drugs used were
positive sign as polypharmacy is known to be a FDCs. A North Indian study reported a higher value
contributing factor for hospitalizations10. It may also of 45% of FDCs12. The use of combination products
lead to drug interactions, adverse drug reactions reduces the number of pills to be taken, cost of
patient and non-adherence. However, in certain packing and dispensing fee. The patient adherence
conditions like cardiovascular problems, the patients may be improved, as lesser number of drugs has to be
may require more than one drug. The recently ingested. There is an inverse relationship between
published Seventh Report of the Joint National patient adherence and the complexity of the

440
regimen13. However, the FDCs may lead to irrational that of a study in Eastern India (3.9%)17,9. The use of
combination as a marketing strategy of the injectable preparation is necessary in cases like
pharmaceutical companies and hence need special insulin, Methyl prednisolone and benzathine
attention. penicillin. Elderly patients may like to have a tablet
whereas for paediatric patients a liquid dosage form
Our study reports only 15% of drugs were prescribed may be appropriate. Appropriate dosage form may
by generic name. Our value is less than that reported also ensure the therapeutic efficacy of drugs and
in other studies8,14. Prescribing by generic name helps reduce toxicity in case of specialized dosage forms
the hospital pharmacy to have a better inventory like film coated, enteric coated, timed release and
control. This will also help the pharmacy to purchase controlled delivery preparations. Patient counselling
the drugs on contract basis, as the number of brands is also essential for patients taking specialized dosage
is less. It can also reduce the confusion among the forms like retard preparations and Gastro Intestinal
pharmacists while dispensing. Generic drugs are Therapeutic System (GITS) preparations.
often more economic than the branded ones.
Prescribing by brand name may be an evidence of Written information for drugs reflects the extent of
vigorous promotional strategies by pharmaceutical pharmacist involvement while dispensing the drugs.
companies. Only 0.4% of medication envelopes had the patient
name labelled on it which is awfully low. However
The percentage of drugs prescribed from the essential 82.6% of the dispensed drugs had drug name and
drug list of Nepal was 40% which is lower compared 87.7% had time of administration mentioned on the
to that of the study conducted in Ghana (93.2%) and envelops. Overall adequate labelling was found only
in North India (75-95%)15,16. The reason for this in 0.4% of the drugs which was much less than the
could be related to lack of awareness about essential 56.2% reported in a study conducted in Eastern
drug concept and essential drug list among India8.
prescribers. It was found that 54.17 % of the drugs
were from Nepalese National formulary and 35.69% Several studies have acknowledged the improvement
were from the WHO model formulary. Prescribing in patient knowledge about medications following
from these formularies can reduce the number of counselling by pharmacists19,20,21. In our study only
irrational combinations entering the market. It can 53.8% of the patients/patient party knew the
also reduce the cost incurred on drugs. administration time and quantity of drugs to be taken.
It was also evident that the age and sex did not
In our study, 28.7% of prescriptions were from the influence the patient knowledge on correct use of
Department of Medicine. The medicine department drugs. The knowledge gained by the patients from the
had the maximum out patient turn over. In this dispensing pharmacist is essential in ensuring patient
hospital, although the numbers of dermatological adherence.
prescriptions were less than prescription from the
department of medicine, the dermatological and The average cost per prescription was found to be
topical products were more in number because the NRS 241.11 (US$ 3.26). A similar study in Western
departments other than dermatology also prescribed Nepal reported the average cost per prescription to be
topical products. (US$2.75 ± 2.21)18. This shows a rise in prescription
cost in the recent past in Western Nepal. Cost is a
Dermatological products were most commonly very important factor in developing countries like
prescribed (17.2%) followed by the drugs acting on Nepal as it can be a major cause for non-adherence.
CNS and antimicrobials. Our results contradict the The results of several studies suggest that up to 10%
result of studies in Brazil and India7,17. A similar of hospital admissions and 23% of nursing-home
study conducted in Western Nepal, two years back admissions are related to non-adherence22. A review
had a different pattern of distribution; antimicrobials of published studies of drug-related hospital
(26.6%) were prescribed more often18. The difference admissions reported that 22.7% of adverse drug
in drug distribution may reflect the disease reaction hospitalizations were induced by non-
prevalence of the study site during the study period. adherence.23 Prescribing cheaper alternatives may be
beneficial in this setting.
The dosage form plays a very important role in
patient adherence. In our study, we found maximum Limitations
use of oral dosage form (79.2%) and 2.1% of drugs The study was conducted during the period of June to
were injectables which is more than that noted in the August and thus the seasonal variation was not
study conducted in North India (0.9%) and less than evaluated. We also had a limited sample size. The

441
selection of prescriptions from different departments governmental organization. Natl Med J India 2000;
may not be representative of the patient population 13(4): 177-82.
attending the OPDs of the hospital. 10. Flaherty JH, Perry HM 3rd, Lynchard GS, Morley
JE. Polypharmacy and hospitalization among older
Conclusion home care patients. J Gerontol A Biol Sci Med Sci
The study suggests that there is immense scope of 2000;55(10):M554-9
improvement in prescribing and dispensing in the 11. Chobanian AV, Bakris GL, Black HR et al: The
hospital. Generic prescribing is urgently needed. The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment
prescribers should be educated about generic
of High Blood Pressure JAMA 2003;
prescribing which may have a multitude of benefits
289(19):2560-2571.
including cost minimization. The lacunae were noted 12. Rehan HS, Singh C, Tripathi CD, Kela AK. Study
in the labelling of drug envelopes by the pharmacists on drug utilization pattern in dental OPD at tertiary
that needs managerial as well as educational care teaching hospital. Indian J Dent Res 2001;
interventions. The study also suggests that a hospital 12:51-6.
formulary encompassing national essential drug list is 13. Haynes RB. A critical review of the “determinants”
urgently required. The Drug and Therapeutics of patient compliance with therapeutic regimens.
Committee of the hospital should take the leading In:Sackett DL, Haynes RB, editors. Compliance
role in rationalizing the prescribing and dispensing with therapeutic regimens. Baltimore:Johns
pattern in the hospital. Hopkins University press, 1976:26-39.
14. Najmi MH, Hafiz RA, Khan I, Fazil FR.
Acknowledgement Prescribing practices: an overview of three teaching
The authors acknowledge the help of the Drug hospitals in Pakistan. J Pak Med Assoc 1998; 48
Information Centre of Manipal Teaching Hospital, (3):73-7
Pokhara, Nepal for providing necessary reference 15. Bosu WK, Ofori-Adjei D. An audit of prescribing
materials in preparing the manuscript. practices in healthcare facilities of Wassa West
district of Ghana. West Afr J Med 2000; 19(4):298-
References 303.
1. Pharmacy communication In Hassan WE editor 16. Biswas NR, Biswas RS, Pal PS et al. Patterns of
Hospital Pharmacy Lea and febiger, Phildelpia, 5th prescriptions and drug use in two tertiary hospitals
edition 1985, 154-1594. in Delhi. Indian J Physiol Phamacol
2. The rational use of drugs: report of the conference 2000;44(1):109-12.
of experts. Nairobi, 25-29 November 1985. 17. Rehan HS, Pal P. Drug prescribing pattern of
Geneva, world health organization, 1987. interns at a government healthcare center in
3. Nepalese National Formulary: First Edition, northern India. Trop Doct 2002;32(1):4-7.
Sep1997 18. Shankar PR, Partha P, Nagesh S. Prescribing
4. Omnibus Budget Reconciliation. Act of 1990, Pub. patterns in medical outpatients. Int J Clin Pract.
L .no. 101-508, and 4401, 104 stat 1388(1990). 2002 Sep;56(7):549-51
5. Dooley M, Lyall H, Galbraith K et al. SHPA 19. Hawkins DW, Fiedler FP, Dougles HL, Eschbach
Standards of practice for Clinical Pharmacy. In RC. Evaluation of a clinical Pharmacist in caring
SHPA practice standards and definitions 1996: 2- for hypertensive and diabetic patients Am J Hosp
11. Pharm 1979:36; 1321-1325
6. Popovich NG. Ambulatory patient care In Gennaro 20. Sczupak CA and Conrad WA. Realtionship
AR editor Remington: The science and practice of between patient-oriented Pharmaceutical Services
pharmacy Vol 2. Mack Publishing Company, and Therapeutic outcomes of ambulatory patients
Pensylvania, 19th edition, 1995; 1695-1719 with diabetes mellitus. Am J Hosp Pharm; 34:1238-
7. Victora CG, Facchini LA, Grassi Filho M. Drug 1242
use in southern Brazilian hospitals. Trop Doct 21. Jaber LA, Halapy H, Fernet M, Tummalapalli S,
1982; 12:231-5. Dewakran H. Evalaution of pharmaceutical care
8. Bosu WK, Ofori-Adjei D. A 1-day survey of drug model on diabetes management. Ann of
prescribing patterns in the District general Hospital Pharmacother 1996:30; 238-242
of the Wassa West District of Ghana. Trop Doct 22. McKenney JM, Harrison WL. Drug-related hospital
1997; 4:222-6. admissions. Am J Hosp Pharm. 1976; 33:792-795
9. Hazra A, Tripathi SK, Alam MS. Prescribing and 23. Col N, Fanale JE, Kronholm P. The role of
dispensing activities at the health facilities of a non- medication noncompliance and adverse drug
reactions in hospitalizations of the elderly. Arch Int
Medicine 1990; 150: 841-5.

442
 Appendix 1

INRUD encounter form

ENCOUNTER FORM
Hospital No Patient Identifier (Name) Age Sex Prescriber Date

Health Problem Description/Diagnosis Department

Health problem

Patient Drug
Prescription Character Label
Knowledge

Patient Drug How

Dispensed When When
Drugs name, strength and dose Name Name Much
Quantity
(0/1) (0/1) (0/1) (0/1) (0/1)

Drugs

443

View publication stats