Author by Dr.Naveen Parmar,PharmD,BCMAS
Ever pondered on what could be the top 3 leading causes of death? As per the study conducted by John Hopkins, medical errors are the third-leading cause of death after heart diseases and cancer in USA; of which medication errors represent 28% of all medical errors.3 Health care is inherently risky, and filling a handwritten prescription could be the most dangerous of all medical procedures. Medication errors, which are often caused by illegible handwriting, are a subgroup of medical errors and may cause as many as 7000 of the 98,000 deaths in the United States each year.2 237 million medication errors occur at some point in the medication process in England in one year.4 These errors takes place in countries which have an advanced health care infrastructure and top medical fraternity. If so is the case in developed countries like USA, UK then what could be the case in developing countries like India?
India is the second most populated country in the world with a population of around 1.32 billion. There is just one allopathic government doctor available for around 11,082 people across the country, a figure more than 10 times the recommended ratio of 1:1000 these figures were revealed in the National Health Profile, 2018, released by the Central Bureau of Health Intelligence — the health intelligence wing of the Directorate General of Health Services under the Health Ministry. There are at present over 7.7 lakh registered ‘AYUSH doctors practicing in India [Ayurveda-428884 (55.4%), Unani-49566 (6.4%), Siddha-8505 (1.1%), Naturopathy2242 (0.3%) and Homeopathy-284471 (36.8%)].5 Ayurveda colleges which have produced hardly 20% graduates practicing their own systems while 80% of the Ayurveda college graduates end up practicing allopathy.5 If all doctors are considered which includes government, private, allopathy, AYUSH practitioners then the doctor-people ratio falls down to 1:921 and if allopathy doctors alone are considered, the ratio soars to 1:1596. From the foregoing narrative it is apparent that neither modern medicine doctors nor AYUSH doctors are available to village. Given the geographical spread of villages and their distance from locations where a doctor is available, people have found solutions which are potentially dangerous. The vacuum has been filled by three kinds of people:
· Unqualified Medical Practitioners (UMPs) who do not possess any recognized medical qualification. These constitute the largest segment of providers.
· Chemists - many of whom have no pharma qualification and are proxies of a person in whose name the pharmacy is run.
· Traditional medicine practitioners -non- institutionally qualified healers, bone-setters, snake venom removers, local traditional herbalists and faith healers
The Health Workforce Analysis report published by WHO, Geneva (2016) revealed that the prevalence of UMPs in India outnumbers that of regular doctors. The study showed that only 58% of the doctors in urban areas had a medical degree and only 19% of those in rural areas possessed a medical qualification; among Allopathic doctors, as many as 31.4% were educated only up to secondary school level; and as many as 57.3% did not have a medical qualification.5 Except the allopathy practicing doctors with proper medical degree, none of the other practicing doctors has pharmacology and pharmacotherapeutics as a part of their curriculum which is the heart of medicine. These mass chunk of doctors prescribes medicines without the knowledge of pharmacodynamics and pharmacokinetics of the drug. Not only has it increased the probabilities of medication errors but also has a risk of causing severe harm to patient’s life.
In India, recording 5.2 million injuries every year due to medical errors adverse events. Topping the list is: 1.Medication errors, 2. Hospital acquired infections, 3.Deep vein thrombosis. Due to the lack of proper health care infrastructure there is under reporting of these errors, which questions the figure of 5.2 million. Some authors estimate that up to 95% of medication errors are not reported.3 The IOM study 2006, showed that only medication errors were harming at least 1.5 million people every year in USA. Following are the primary factors which increases the risk and probabilities of medication errors in India:
· Less allopathy doctor to people ratio
· AYUSH doctors practicing allopathy
· Unqualified and unlicensed Chemist practicing medicine
· Unqualified medical practitioners and traditional medicine practitioners
The NCCMERP (National Co-coordinating Council for Medication Error Reporting and Prevention) defined medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient or the consumer. The prescription and administration phases of the medication process are the most common points where errors occur. Of the 237 million medication errors in England, prescribing errors constitute 21.3% of errors, administration errors constitute 54.4% of errors and dispensing errors constitute 15.9% of errors. There are multiple studies conducted in India on medication error which are limited to hospitals. The incidence of errors also varies from hospital to hospital. A study conducted by N Patel et al. at Civil Hospital, Ahmedabad observed 36% of medication errors of which 65% prescription error, 31% administration error and 4% dispending error. In another study conducted by Purushothama et al. at RIMS, Kadapa the incidence of medication error was 66.32% of which 80.46% were prescribing errors. Prescribing errors included wrong dose, wrong duration, wrong route, wrong drug, wrong dosage form etc. Polypharmacy is also one of the reason for medication error. Polypharmacy is most common in the elderly, affecting about 40% of older adults living in their own homes.6 Doctor in India also practice polypharmacy. In a study by KB Rakesh et al. 66.19% patients were receiving polypharmacy. It has been claimed that patients taking two drugs face a 13% risk of adverse drug interactions, rising to 38 % when taking four drugs and to 82 % if seven or more drugs are given simultaneously. With polypharmacy, duplicative prescribing within the same drug class is prevalent and unrecognized drug adverse-effects are often treated with more drugs thus leading to prescribing cascades.
Numerous medication errors go unrecognized and are not detected or reported. Tragically, however, some medication errors result in serious patient morbidity or mortality. Thus, medication errors must not be taken lightly, and risk-reduction strategies and systems should be established to prevent or mitigate patient harm from medication errors. With the introduction of new breed of doctors in India who has expertise in pharmacology and pharmacotherapeutics, these medical professionals can fill the gaps in the Indian health care system and become an integral part of patient care. The PharmD professionals after completion of 6 to 7 years of education can work in a hospital setup and conduct ward rounds independently or with consultants to optimise the medication therapy. According to a study published by BMJ Quality & Safety these professionals may be more efficient than other health care professionals when it comes to preventing medication errors in the emergency department (ED). In the study, the authors found that having PharmD professional take medication histories of patients in the ED can reduce mistakes in drug orders by more than 80%. PharmD professionals not only help in detecting the ADR but also play an important role in monitoring patient medication therapy.
These drug experts can review the prescription before it is processed which could prevent multiple errors before the drug reaches the patient. PharmD professionals also has an active role in selection of the drug for a particular disease condition, dosage adjustment, managing the pharmacotherapy, monitoring the therapy and finally counselling patients on drugs, disease and life style modification. The fast growing rates of medication errors all over the world decides the need for starting a routine prescription auditing and patient monitoring in all the community, multispecialty and tertiary healthcare centres in India. Also, Looking at the number of unqualified doctors and the increased risk of medication errors in India, it’s the need of an hour for PharmD professionals to step in and fill the gaps in the health care system. So, next time when you see more number of drugs in you prescription; be wise enough to get it reviewed by PharmD professional who could be a pharmacotherapist, clinical pharmacist or clinical pharmacologist.
1. BMJ 2016; 353
2. N Engl J Med 357;6
3. JBI Database System Rev Implement Rep 2018; 16(2):291–296.
4. EEPRU Feb 2018
5. S. Chandra, K. Patwardhan / Journal of Ayurveda and Integrative Medicine 9 (2018) 143e150