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ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 6  |  Page : 701-706  

A survey of knowledge of interns about the instructions given to the patients while prescribing various dosage forms


Department of Pharmacology, B.J. Government Medical College and SGH, Pune, Maharashtra, India

Date of Web Publication16-Nov-2016

Correspondence Address:
Mahendra Mahadu Gaikwad
Room No. 17, Chhatrapati Shivaji Maharaj New Resident, Doctors Quarters, 3 Church Road, Behind St. Helena's School, Pune - 411 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.194185

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  Abstract 

Introduction: Education of health care providers regarding the proper use of dosage forms is inadequate, contributing to prescription errors. Objectives : The objective of this study is to assess the knowledge of interns regarding the dosage forms and their administration techniques. Materials and Methods: Interns ready to solve questionnaire were allotted to Arm A (n = 153). For each correct multiple choice question (MCQ) answer scored "1" and each incorrect or unanswered MCQ was given "0" mark. The percentage marks obtained was calculated and re-allotted grade as per 10 point grade scale. The participants in Arm B (n = 93) had to perform demonstrations. Demonstrations which included metered dose inhaler (MDI), insulin injection, eye drops, and nasal drops were performed. Score "1" for correct step and score "0" for incorrect step was given. Percentage of interns solved each step in a demonstration was calculated. Both Arm A and B analyzed separately. Results: Analysis of the questionnaire (Arm A) showed the following grades: 6.54%, 24.18%, 28.10%, 22.88% 13.73%, and 4.57% i.e. interns scored grades as excellent, very good, good, satisfactory, sufficient to pass, and fail, respectively. In demonstration techniques (Arm B) for use of MDI, nasal drops, eye drops, preparation of 40 U of 10 U humulin-R and 30 U humulin-N in one syringe and subcutaneous administration of premixed insulin were assessed and it was observed that respectively 13.98% (13/93), 10.75% (10/93), 2% (2/93), 1% (1/93), and 27.96% (26/93) interns could demonstrate correctly. Conclusion: This study suggests theoretical knowledge is not sufficient. Very Few interns could demonstrate correctly this explains the need for emphasis on such exercises in curriculum.

Keywords: Demonstration techniques, dosage forms, interns, knowledge


How to cite this article:
Gaikwad MM, Dabhade SS, Jagtap RP, Ghongane BB. A survey of knowledge of interns about the instructions given to the patients while prescribing various dosage forms. Med J DY Patil Univ 2016;9:701-6

How to cite this URL:
Gaikwad MM, Dabhade SS, Jagtap RP, Ghongane BB. A survey of knowledge of interns about the instructions given to the patients while prescribing various dosage forms. Med J DY Patil Univ [serial online] 2016 [cited 2024 Mar 29];9:701-6. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2016/9/6/701/194185


  Introduction Top


In pharmacology, the emphasis is given on the active drug substance, its dose, clinical effects and adverse drug reactions. However, the formulation of drug is also essentially important as it determines whether the dose can be effectively delivered to the patient or not. Reasons for the formulation of drugs into various dosage forms are to protect active drugs from degradation when administered orally and they may be required for rate controlled action or optimization of delivery of topical or inhalational drugs. [1] For example, enteric-coated oral tablets have coating that protects the tablet from stomach acidity and protects the lining of gastrointestinal tract from irritation by the drug. Osmotic pump is a very sophisticated extended-release system that delivers medication slowly over the time. [2]

The effectiveness of a drug depends not only on its chemical content but on the information which is given to the patients. [3] Out of total prescribing errors, medication dosage form errors accounts for more than 10%. [4] In addition to causing serious morbidity and mortality, dispensing errors increase the economic burden on society by adding to health care cost. [5]

Improper use of the medication delivery device in chronic obstructive pulmonary disease (COPD) is noted, and misuse of the inhaler has been reported to be as high as 90%. [6] Incorrect technique of administering inhaled medication prevents patients with asthma or COPD from receiving the maximal benefit from their medications. A study suggested that as many as 25% of patients with asthma or COPD have never received verbal inhaler technique instruction and only 11% of patients received follow-up assessment and education on their inhaler technique. [7]

Medication should never be given by health care team until its possible side effects, precautions, recommended dosages, dosage forms, and administration techniques are known. Swallowing a tablet or a capsule is the most common way people take medications, other routes of administration are suppositories and inhalers which may be used to deliver medications into the body. [8] Although drug efficacy and safety has traditionally been considered as predicted by dose, frequency and bioavailability. It is also apparent that proper method of administration also influences and can determine drug effect. [9]

As conventional dosage forms of drugs are rapidly being replaced by new and novel drug delivery system, it is important to have the knowledge regarding these newer dosage forms. Hence, doctors should also be able to handle the drug properly or advise the patient about its administration technique. Wrong technique can cause failure of therapy.

Taking into consideration the background knowledge, this study was planned in interns with the aim to assess the knowledge of interns regarding - The instructions to be given to the patients while prescribing various dosage forms and their administration techniques. Interns are medical students who complete their MBBS course and actually start prescribing medicines to the patients.

Aims and objectives

To assess the knowledge of interns regarding:

  • The instructions to be given to the patients while prescribing various dosage forms
  • The dosage forms and their administration techniques.



  Materials and Methods Top


This was a prospective observational study. The two aims of the study were considered as two separate arms in this study. They are Arm A and B.

All the interns included in the study were belonging to February 2015 batch who attended orientation program in a government medical college attached to a tertiary care hospital. An approval from institutional ethics committee was taken.

Out of 200 interns, 153 who were ready to solve questionnaire were allotted to Arm A. Ninety-three out of 153 who were ready to participate in demonstration technique of particular dosage forms were allotted to Arm B.

The participants belonging to Arm A (n = 153) had to answer a questionnaire that consisted of twenty multiple choice questions (MCQs). These questions were framed on the basis of information to be given to patients regarding various dosage forms, which mainly included questions on most commonly prescribed dosage forms required in day-to-day medical practices. This informative material is published in second year M.B.B.S. journal of MUHS, Nashik. The analysis of MCQs was done by a marking system, where each correct MCQ answer scored "1" mark, and each incorrect or unanswered MCQ was given "0" mark. The percentage marks thus obtained by each intern was calculated. Depending on this percentage marks each of the participants was re-allotted a grade as per 10 point grading system of Indian Institute of Technology. [10] Thus, finally in the questionnaire assessment, each participant scored a particular grade. The final step in the analysis of this arm was to calculate the percentage of students scoring a particular grade as per 10-point grading system. Arm A was considered separately for statistics in all respects for this study.

The interns who had given consent to perform objective structured practical examination (OSPE) were included in Arm B (n = 93). The participants belonging to Arm B had to perform a demonstration. Demonstration of some commonly prescribed dosage forms which include metered dose inhaler (MDI), insulin injection, eye drops, and nasal drops were performed by the participants. For this dummy kits were prepared. Checklists for these OSPE were prepared using journals in their curricula for the effective administration of these specialized dosage forms. Steps performed by each intern for the demonstrations of how to use MDI, how to administer an eye drops and nasal drops, how to prepare a total 40 U using a 10 U humulin R insulin and 30 U humulin N insulin in one syringe and how to administer premixed insulin subcutaneously were evaluated on the basis of checklist of respective OSPEs for that demonstration. Score "1" for correct step and score "0" for incorrect or missed step was given. Every intern had performed five demonstrations. Percentage of interns solved all the steps in a demonstration as well as the percentage of interns solved each step in a demonstration was calculated. Arm B was considered separately for statistics in all respects for this study.


  Results Top


  • Arm A ® Analysis of questionnaire-based group: (n = 153)


  • Analysis of questionnaire showed that only 6.54% (10) interns scored grade points 9-10 (i.e., excellent), 24.18% (37) interns scored grade points 8-9 (i.e., very good), 28.10% (43) interns scored grade points 7-8 (i.e., Good), 22.88% (35) interns scored grade points 6-7 (i.e., Satisfactory), 13.73% (21) interns scored grade points 4-6 (i.e. Sufficient to pass), and 4.57% (7) interns scored grade point 3-4 (i.e., fail) [Figure 1]. <50% intern answered correctly to the three important MCQs. Two of them were framed on suspension, one was regarding the preparation of reconstituted suspension for oral use with water (distilled, saline, boiled, and cooled) to be added; another was on, within how many days freshly reconstituted suspension should be used and the third one on glyceryl trinitrate (GTN) (nitroglycerin) transdermal patch which asks about what instruction should be given to a patient to avoid tolerance due to GTN transdermal patch.
  • Arm B ® Analysis of demonstration-based group (OSPE): (n = 93)


  • Demonstration on various commonly used dosage forms such as MDI, eye drops, nasal drops, and insulin injections was performed by the intern during OSPE examination. Results showed that:

    1. For MDI, only 13.98% (13) interns demonstrated all the steps in correct sequence. 23% (21) of interns missed to demonstrate the important step of pressing the top of canister and synchronizing this action with slow inhalation. 51% (47/93) missed to give the instruction that after complete inhalation of drug, hold the breath for about 10 s and then breathe out slowly [Figure 2]
    2. In the exercise on demonstration of nasal drop administration 10.75% (10) interns were able to demonstrate all the steps for nasal drops. 62% (58) were missed to give an instruction that after instillation of nasal drop, rest in the same position for a minute.
    3. In the exercise on eye drop, only 2% (2) were able to demonstrate all the steps in correct sequence for eye drops, whereas 42% (39) interns missed the instruction like making a pouch in medial canthus before instillation of eye drop to prevent spillage of a drug
    4. In a demonstration for preparing total 40 U insulin using 10 U of humulin-R and 30 U of humulin-N in one syringe: Only 1% (1/93) of interns were able to demonstrate all the steps in correct sequence. 73% (68/93) of interns could not even perform a single step for this demonstration [Figure 3]
    5. Regarding demonstration of how to administer premixed insulin subcutaneously: Only 27.96% (26/93) were able to demonstrate all the steps [Figure 4].
Figure 1: Grades obtained and percentage of interns

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Figure 2: Metered dose inhaler-number of steps demonstrated

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Figure 3: Percentage of interns performed steps in objective structured practical examination for preparation of 40 U of insulin in one syringe (10 U humulin-R and 30 U humulin-N)

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Figure 4: Percentage of interns performed steps in objective structured practical examination for premixed insulin subcutaneously

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  Discussion Top


Medication dosage formulation is an important method of improving the utility of pharmacological agents. [11],[12] Changing the way in which a dosage form is presented can alter its absorption characteristics, result in medicines instability, produce local irritant effects, causes failure to reach the site of action, may produce safety issues. [13]

Formal education of health care providers and patients regarding proper use of various dosage forms is inadequate contributing to number of prescription errors. Hence, the inclusion of basic information regarding the role of dosage forms in pharmacology and therapeutics courses for doctors, nurses, and pharmacists is necessary. [14]

Splitting or crushing sustained release (SR), extended release (ER), controlled release (CR), or gastrointestinal therapeutic system (GITS) oral dosage forms may produce changes in the drug pharmacokinetics and bioavailability resulting in underdosing or adverse effects. [15] In this study, 71.7% interns responded correctly to the question framed on "preparations not to be crushed or chewed." Which suggest that while learning dosage forms instead of just telling that SR, CR, ER, and GITS preparation should not be crushed, some case study should be explained to the students so as to explain the disadvantages of crushing such dosage forms.

A study found that high degree of tolerance which leads to decreased efficacy of the drug during continuous therapy with nitroglycerin (GTN) patches and suggested that tolerance can be prevented by 12-h-daily intermittent therapy. [16] In this study, only 42.8% interns responded correctly to the question framed on instruction for GTN transdermal patch indicating lack of awareness about this topic among majority of interns.

Effectiveness in delivering drugs to the lungs for treatment of asthma depends on correctly performed inhalation maneuvers and studies shown that up to 85% of patients do not use their inhalers correctly, hence to acquire the skills required for using these medications, health professionals, and patients must be adequately educated and trained. [7] In this study, 86% of interns were found unaware of all steps in proper sequence for correct administration of drug using MDI. If MDI is not used correctly this leads no relief from bronchial asthma which may worsen patient condition and may require admission in the hospital. This study also shows the need for training of interns on this aspect through hands on (actual demonstration) practical in their curriculum though it is taught in 2 nd year M.B.B.S. in pharmacology.

Systemic absorption of eye drops and ointments occurs via the conjunctival blood vessels or the nasal mucosa that can lead to adverse reactions. These effects can be reduced by instructing the patient to apply digital pressure to the tear drainage system at the nasal corner, i.e., canthus of eyes, which can minimize the amount of drug being taken into the nasolacrimal system and the systemic circulation. [17]

As regards to this study, 66.67% interns missed to demonstrate the important step of pressing canthus for 30-60 s after instillation of eye drops, again emphasizing the need for practical training.

Medication errors involving insulin are common and may cause severe harms or even death. [18] Insulin-related errors were more frequently observed during the administration stage (61%) compared with prescribing and dispensing. [19]

In relation to a number of serious errors in the administration of insulin by clinical staff, the National Patient Safety Agency (NPSA) issued a Rapid Response Report, Safer Administration of Insulin (NPSA, 2010), for health care professionals. It focuses on the training program to be put in place for all healthcare staff (including medical staff) expected to prescribe, prepare, and administer insulin. [20]

In the context of this study, while demonstrating how to prepare 40 U from 10 U humulin-R and 30 U humulin-N in one syringe, 99% interns were unaware of all the steps in proper sequence. The important step, which insulin should be drawn into the syringe first was unknown to 73% of interns. If interns are unaware of doing such important step, it will lead to postprandial hyperglycemia and complications of not having glycemic control.

The shorter-acting insulin should be drawn into the syringe first to avoid contaminating the short-acting insulin preparation with longer-acting insulin. The zinc in ultralente retards the onset of action of the regular insulin. [21]

When searched for references related such errors of mixing two-insulin (short-acting and longer-acting) in one syringe, not a single reference found. This may be because 'erros of mixing two insulins' has not been given importance while administering two different insulin by a conventional method in one syringe.

Hence, merely just having visual impression about the various dosage forms is not sufficient but the practical aspects of how to use conventional as well as newer dosage forms correctly for effective therapeutic benefits is also very important. Hence, practicing physician, medical students, and nurses must have theoretical as well as practical knowledge about all dosage forms available with respect to the importance of correct techniques of administration as well as disadvantages of the incorrect use of dosage forms.

The novelty of the study lies in the simple fact that it assesses the knowledge and application gap about dosage forms. Although to some extent the MBBS students did have dosage related theoretical knowledge, they failed to demonstrate the appropriate application of this. In few instances, the students totally lacked knowledge itself and were unaware of important fact and details regarding dosage forms and their administrations. These gaps directly or indirectly affect therapeutic outcome. Therefore, promoting the false need for more effective new drugs, it also hints that there is a need to emphasize the dosage related aspects. It also highlights the need to include in the curriculum the demonstration and practice of drug administration under the psychomotor domain so as to produce more knowledgeable and confident doctors of tomorrow.


  Conclusion Top


This study suggests that only having theoretical knowledge is not sufficient. As very few interns could reveal the techniques correctly, this study explains the need for more emphasis in curriculum on the commonly prescribed dosage forms available in the market and their demonstration techniques.

Acknowledgment

Authors would like to acknowledge Department of Preventive and Social Medicine, who arranged a session for the conduct of this study in orientation program of interns run by the department.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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