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Improving the rational use of drugs in the Kalahari Region of

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					Improving the rational use of drugs in the Kalahari
          region of the Northern Cape.



        Northern Cape ISDS Technical Report # 2




Compiled by:
Dr. Catherine Orrell, Rational Drug Use Training Programme, Department of
Pharmacology, University of Cape Town

Data collected by:
Mrs. Elna van der Walt, Regional Pharmacist, Kalahari region
Matron Vienna Manong, Regional PHC co-ordinator, Kalahari region
Contents:

Contents: ........................................................................................................................ 2
Introduction: .................................................................................................................... 3
Methods: ......................................................................................................................... 3
   Components of improving rational drug use: ............................................................... 4
      1. Implementing a stock management system ...................................................... 4
      2. Training in rational drug use:............................................................................. 5
      3. Measuring drug use indicators: ............................................................................ 6
   Information flow: .......................................................................................................... 7
Results:........................................................................................................................... 7
   Components of improving rational drug use: ............................................................... 7
      1. Implementing a stock management system: ..................................................... 7
      2. Training in rational drug use:............................................................................. 8
      3. Measuring drug use indicators: ......................................................................... 8
   Information flow: ........................................................................................................ 11
Future training plans: .................................................................................................... 11
Expansion to the rest of the Northern Cape: ................................................................. 12
Conclusion: ................................................................................................................... 13
Appendix:...................................................................................................................... 14




                                                                                                                                   2
Introduction:

The Rational Drug Use Training Project first visited the Kalahari region in August of
1997. A two-day workshop was presented to the regional health director, the regional
chief professional nurse (CPN) and staff from each of the seven fixed clinics in the
region. The problem-based course covered:

•    Principles of rational prescribing and dispensing,
•    Use of therapeutic guidelines, focusing on the essential drugs list (EDL),
•    The collection and collation of drug use indicators, and
•    Principles of managing stock (medicines) by means of a stock card system.
(Details of the Rational Drug use Training Project are available from Catherine Orrell <correll@uctgsh1.uct.ac.za>)

Staff agreed to apply these principles to their daily practice, with support from the
regional CPN. Stock cards were supplied and introduced at a few of the clinics. Drug use
indicators would be collected and the stock cards monitored by the regional pharmacist,
whose employment was imminent. It is impossible to improve drug use patterns in a
consistent and sustainable manner without the leadership of regional or district
management staff.

From January 1998, with a complete regional team of pharmacist and CPN/nurse
trainer, the plan for monitoring and improving the prescribing in the region was
formulated. This report details the progress made during 1998 and the plans for 1999.



Methods:

By January 1998 the regional pharmacist had been appointed. She was given
responsibility for the overall management and supply of drugs to the region. In order to
define the role that the regional management staff must play in supervising and
maintaining rational drug use processes, a meeting of regional training staff and the
Rational Drug Use Training Project team was called.

Since the initial workshop Vanzylsrus and Kathu clinics had implemented a stock card
system to manage their stock. The system was running successfully already. Two other
clinics, Kuruman and Danielskuil were beginning the process. The sisters at Vanzylsrus
had asked to have cough syrup removed from their stock, as they felt it was being
irrationally and unnecessarily prescribed. The regional CPN had initiated regular
meetings at each of the clinics, for discussion of clinical cases. Monthly combined clinic
meetings were also planned for continuing education purposes. These processes
needed to be co-ordinated and monitored.

The objectives of the meeting were:

1. To plan a systematic approach toward implementing rational drug use systems in the
   Kalahari Region, Northern Cape. The management staff would be the key people in
   taking any initiatives to the primary care staff.


                                                                                                                      3
2. To define the technical and drug information support the regional and district staff will
   need from the Rational Drug Use Training Project.
The plans made are detailed below.


Components of improving rational drug use:


1. Implementing a stock management system

Prior to August 1997 none of the clinics in the Kalahari region had any system of
managing drug stock. Primary care staff manually counted their stock each time they
placed an order. Receipt and issue of drugs was not recorded and there was no fixed
chain of accountability. Many dispensaries in the region are small, too warm and
overcrowded with boxes of surplus drugs, a large number of which are not from the
primary care essential drugs list.

Since the first presentation of the Rational Drug Use Training Project two of the seven
full-time clinics in the Kalahari region had implemented a stock card system. Two other
clinics were in the process of doing so. The other clinics (3 full-time and 3 part-time)
have not. The reasons given are that the clinics are too busy and short staffed to spend
time initiating a system of stock management.

Some system is required to identify old, unused, and damaged drugs. Non-essential
drugs (those not on the primary care EDL) must be removed. The process of ordering
needs to be streamlined and regulated. A stock card system is one of the simplest
methods to record receipt, issue and stock balance. The responsible party signs each
entry. The regional pharmacist has agreed that such a system must be implemented in
the Kalahari region. She would co-ordinate and supervise this process, which would
have to be completed by clinic staff, either by the sister herself or by a staff nurse or
clerk supervised by the sister.

A stepwise process was planned:
a. The stock cards available were quite complex. They needed to be simplified and
    printed for use at all primary care facilities in the region. Provincial support was
    sought for the printing process. Until provincial cards were available photostats of
    available cards were used.

b. During February and March 1998 the regional CPN and pharmacist visited each of
   the 10 primary health care facilities in the district. They discussed the process and
   advantages of a stock card system with the staff. Co-operation of at least one staff
   member, and preferably all, per site was needed for implementation.

c. The regional pharmacist reviewed existing stock management systems by the end of
   March 1998. The Rational Drug Use Training Project’s “facility-based drug indicator”
   sheet contains a list of 10 medicines, adapted from a WHO sample list, each of
   which should have their stock card checked to give an overview of the system at
   each site. Staff were consulted and asked to note the benefits and problems they
   have had with the system. Any adaptations must be made to this system before
   implementation in the new sites.


                                                                                            4
d. The adapted stock card system was then to be implemented by the other clinics by
   the end of May 1998. Regular (initially monthly) visits by the regional CPN and
   pharmacist will ensure the facility staff is adequately supported.

e. In the future less frequent visits would be needed. District staff could report problems
   directly to the regional pharmacist. In time the role of stock card review would be
   given to a pharmacy assistant, should such a post be opened.

f.   The staff of the Rational Drug Use Training Project was available throughout for
     queries and discussion on the implementation process.



2. Training in rational drug use:

The regional CPN had the responsibility of providing and co-ordinating continuing
medical education of primary care staff in the Kalahari region. Since her appointment in
September 1997 she had organised monthly meetings of all the clinic sisters to discuss
common problems, as well as encouraging on-site early morning meetings to review
clinical cases. She visits all the clinics at least once a month.

Most of the clinic staff had become familiar with the process of rational prescribing as
taught by the Rational Drug Use Training Project. They either attended the August 1997
workshop themselves, or they had received input from staff who did attend.

This process of rational prescribing should form a framework for any continuing
education held in the region:


            Step 1: Define the patient's problem

            Step 2: Specify the therapeutic goal
            What do you want to achieve with the treatment?

            Step 3: Choosing suitable treatment
            Check effectiveness and safety of your choice. Do you NEED
            to use a drug?

            Step 4: Start the treatment
            Write a correct prescription

            Step 5: Give information, instructions and warnings
            And check the medicines are labeled correctly

            Step 6: Monitor (and stop?) treatment


A monthly teaching timetable was to be drawn up, listing topics that would be taught to
the clinic staff during the CPN’s visits. Teaching will be done on site, in small group,



                                                                                           5
face-to-face format. Lessons will be based on clinical cases that the staff must manage
according to rational prescribing principles. For example, the CPN was attending up-to-
date training on tuberculosis. The information she learnt would be disseminated to the
staff within a month. She may develop a number of TB-related cases that bring up points
for discussion and learning.


3. Measuring drug use indicators:

Monitoring the above processes is essential to determine efficacy and improvement in
practice. A system of collecting and collating drug use indicators had been presented to
the primary care facility staff during the first Rational Drug Use Training Project
workshop in the region. A small sample of indicators had been collected at Kuruman
clinic. The Northern Cape Provincial Department of Health had used similar indicators.

These indicators audit prescribing and dispensing practices of both doctors and nurses.
Compliance with treatment guidelines can be determined. Collecting indicators on a
regular basis (perhaps 6 monthly) should be considered part of the role of any sister-in-
charge. The results are anonymous and CANNOT be traced to any particular prescriber.
This is explained to clinic staff, but it is still expected that most will place more emphasis
on their prescribing on the day they are monitored. At present it is not feasible to do
prescription collection without the knowledge of the prescribers.

a. From January to March 1998, the regional CPN would discuss the advantages of
   monitoring drug use practices with staff at all the clinics. Training sessions (probably
   2 per site) in indicator collection were to be held with these staff.

b. From March to May 1998 a hundred baseline “prescription-based” indicator forms will
   be collected at each Kalahari clinic. Baseline “facility-based” indicators will be
   collected too.

c. Collation of the indicators would be completed thereafter. Feedback will be given to
   all clinics and a report written for the Initiative for Sub-District Support and the
   Provincial Department of Health. Presentation of the results at the Health Systems
   Trust research conference in September 1998 was planned.

d. Collection of indicators will be repeated annually, to continue monitoring as on-site
   training and stock management systems improve rational drug use habits. The
   regional staff must record all training and pharmacy input received at each
   site.

The nurse trainer should emphasise the importance of following treatment guidelines
among the nursing population. This may be more of a problem among the doctors.
Regional directives may have to be set to ensure compliance here.




                                                                                             6
Information flow:

There are drug information resources available to staff in this region. On-site, each clinic
should have a copy of the South African Primary Care Essential Drugs List, as well as a
Medunsa Primary Health Care Formulary. Regional staff are available for clinical and
pharmaceutical queries, and have access to a number of texts. Query topics will be
recorded, and collated to motivate for updated literature. Regional and clinic staff also
have access, via telephone, e-mail or fax, to the Primary Health Care Medicines
Resource Centre in Durban, or the Medicines Information Centre in Cape Town. All
medicine or treatment guideline queries can be directed these two centres, which
provide up-to-date, unbiased and user-friendly information.

The problem lies in that these resources are not being utilised by the primary health care
staff. Staff, both nursing and medical, need to be encouraged to ask questions and to
seek the answers themselves. The best means of encouragement will be through the
regular teaching sessions, which should initiate queries. Having approachable,
encouraging regional staffs, who visit the clinics frequently, should make asking
questions less intimidating. Collating the queries received will show the frequency with
which the resources are used over time.



Results:


Components of improving rational drug use:


1. Implementing a stock management system:

Progress is slow on the stock management side. By October 1998, there was some
level of stock control at most of the Kalahari region clinics. Some staff are still resistant
to the process of using stock cards, claiming they do not have the time. However,
regional staffs have noted, after the time they have spent in the clinics, that in the
majority of clinics there is definitely time available, either between patients or in the
afternoon. In the busier clinics Mrs. van der Walt is investigating the use of a simpler
tally sheet system. The importance of stock management is constantly reinforced-
systems are being continually refined and improved.

There were no drug shortages on the days the indicators were collected. 99.5% of the
prescribed drugs were available to be dispensed. This reflects very favourably on the
drug supply system.




                                                                                                7
2. Training in rational drug use:

The monthly meetings with the clinic nurses have gone ahead as planned. The focus
this year has been on the management of tuberculosis. Specific training on rational drug
use has not been given. Training will be focussed on in 1999 (see Future Training
Plans).



3. Measuring drug use indicators:

A set of drug use indicators from 8 primary health care facilities was collected over 10
working days in August. Some clinics were visited twice. Fifty prescribing indicator
sheets (see Appendix) were collected from the larger clinics (Kuruman, Danielskuil,
Olifantshoek and Postmasberg), thirty from the smaller clinics (Wrenchville and Dibeng),
ten from Dingleton and six from Kathu.

The goal was to gain an overview of prescribing habits in the Kalahari region. Individual
clinics cannot be compared. For that purpose, at least a hundred encounters must be
recorded at each clinic. All prescribing data is anonymous and cannot be traced to any
particular prescriber. The data can be used to identify areas of irrational prescribing,
which may be harmful to patients and lead to overspending. Directed training can then
be implemented to address these problems.

Results are as follows:

Indicator being measured             Total (out of):    %               ideal
Number of scripts                    282 (282)          -               -
Patient name on the script?          282 (282)          100%            100%
Prescriber signature on the          281 (282)          100%            100%
script?


Total number of drugs prescribed     585                -               -
at each clinic (all prescriptions)
Drugs per prescription (total        2.08               -               1.2 to 2.0
number divided by number of
prescriptions)


Number of drugs from the EDL         541 (585)          92.5%           100%
Number of drugs prescribed by        437 (585)          74.7%           100%
generic name




                                                                                            8
Indicator being measured             Total (out of):     %              ideal

Number of drugs with a correct       282 (585)           48%            100%
prescription line (all 4 points
correct)
Number of drugs labelled             458 (585)           78%            100%
correctly (all 4 points)


STG followed completely (given a     223 (282)           79%            100%
3)
Almost all points followed (given    41 (282)            14.5%
a 2)
Not followed at all (given a 0)      8 (282)             2%             0%

Number of drugs dispensed?           582 (585)           99.5%          100%

Patient’s knowledge excellent      64 (282)              23%            100%
(given a 3)
Patients knowledge reasonable      116 (282)             41%
(given a 2)
Patients knowledge terrible (given 10 (282)              3%             0%
a 0)


Average cost of each prescription    Not complete        Not complete   Under
                                                                        R10.00

Number of drugs which were           117 (585)           20%            <25%
antibiotics?
Number of drugs which were pain      154 (585)           26%            -
killers?
Number of drugs which were           25 (585)            4.2%           -
vitamins?
Number of drugs which were           1 (585)             0.1%           -
injections?



STG = standard treatment guideline.
The last 4 variables are optional, but very useful to know.



                                                                                 9
Achievements:

In general the prescribing habits in the Northern Cape are positive. The average drug
per prescription rate of 2.08 is close to the ideal WHO recommended range. There are
marked improvements in prescribing from the Essential Drugs List (92.5%) compared to
the Northern Cape baseline study, collected by the Department of Health in 1997 (78%
for clinics)1. Similarly generic prescribing has increased (74.7% compared to 33.9% in
the baseline study). Percentage antibiotic prescribing seems to be less (20% in
comparison to 38%), as well. All these improvements will increase the quality of the care
received by the patient.

Barely any injections are used. This may have the benefit of decreasing the risk of
needlestick injury to health care staff. Injections are also expensive. Treatment
guidelines are being followed to a large degree. All clinic staff have access to the green
EDL book with the recommended treatment guidelines for primary care.

Problems:

There are a few problem areas. Prescription writing is poor- only 48% of scripts
contain enough information to allow correct dispensing and therefore ensure patient
safety. Commonly the strength of a medication, especially a syrup, is omitted and the
recommended duration of therapy is not recorded. No instructions are given for
application of creams or ointments. Labeling is complete in 78% of dispensed
medicines. Again it is the ointments, with no stick on labels, that are a problem.

Patient knowledge of medication can be improved. More time should be spent by staff
on this aspect. The health care workers may have inadequate knowledge of drugs
themselves, and so not be able to pass this information on to the patients. They have to
address this by seeking the necessary information (even if in front of the patient!) by
asking others, using a reference book or contacting a medicines information centre.

Antibiotics and analgesics are markedly over prescribed (20% and 26% of the total). If
it is considered that in total 282 patients were seen, then about 40% (117/282) of these
people received an antibiotic and 54% (154/282) received an analgesic (paracetamol,
NSAID, aspirin or codeine). This is exceptionally high and, in a large proportion of the
cases, probably completely unnecessary.

Combinations of analgesics are frequent, usually of different types, but occasionally two
non-steroidal anti-inflammatory drugs are prescribed together, or two preparations
containing paracetamol. This could be lessened if generic names were used. Training is
needed in the rational use of these drugs.

Other points noted during collection:

•     Some staff use the term “ante-natal care regime” as a prescription. This refers to an
      inconsistent combination of vitamin Bco, folate, vitamin C or ferrous sulphate. These
      drugs MUST be correctly prescribed.

1
    Northern Cape Baseline Study 1997. Page 16.


                                                                                         10
•   “Grip-pille”, a combination product of paracetamol and pseudo-ephedrine are
    commonly prescribed. This product is not on the EDL. If used, the generic names
    must be written to avoid combination with paracetamol tablets/syrup.
•   Patient flow through a number clinics is poor.
•   One clinic is dispensing aqueous cream in their TTO bags!



Information flow:
Staff are improving in their use of information. Most questions are directed to the
regional pharmacist who in turn uses either the Northern Cape pharmaceutical services
manager or the Medicines Information Centre in Cape Town to answer her queries.
Unfortunately the Primary Care Medicines Information Centre in Durban-Westville is no
longer operational.

Patient knowledge does remain a problem. This partially reflects poor staff knowledge.
Improving patient knowledge is one of the goals for 1999.



Future training plans:

Four problem areas will receive input in the next 6 to 9 months. The drug use indicator
collection revealed problem areas, the most obvious of which have been selected for
training. For each topic an interactive workshop will be prepared. Each workshop will be
of 1 to 2 hour’s duration so it can be presented and repeated, if needed, over a lunch
hour at a clinic, making use of the regional CPN’s regular visits. Back-up drug
information will be provided as well.

1. Prescription writing and labeling:
   • Importance of complete prescription information (dispensing accuracy, patient
      safety, different tablet strengths e.g. ibuprofen, ciprofloxacin).
   • Importance of correct labeling (patient clarification, expiry date).
   • Using some prescriptions collected in August 1998, ask the staff for problems
      they may have in interpreting it. What do the patients need to know?

2. Patient knowledge:
   • Role-play on educating the patient. What would staff want to know about their
      medicines if they were ill?
   • Encourage use of books, e-mail and other resources during the patient
      consultation.
   • Ways of improving patient knowledge (write the instructions down, get them to
      repeat the information back to you).

3. Antibiotic prescribing:
   • Are we over-using antibiotics? When are they appropriate (viral vs. bacterial
     infections)?
   • Overview of penicillin, amoxicillin, erythromycin and co-trimoxazole.



                                                                                      11
4. Analgesic prescribing:
   • Is it necessary to prescribe an analgesic? When are they appropriate?
   • Overview of paracetamol, aspirin, codeine and non-steroidal anti-inflammatory
     analgesics.
   • Problems with combinations and over-use of these drugs.

Themes to pull through all the training sessions:
•   Encourage generic prescribing.
•   Avoid the use of combination tablets.
•   Encourage the use of treatment guidelines- and use as few drugs as possible!


Further information can be gleaned from the 282 prescriptions collected. As yet cost
analyses have not been done. Prescriptions can be analysed by disease process or
diagnosis, to assess present skill in the management of a particular illness.

The next complete Kalahari region set of drug use indicators will be collected in June
1999, after completion of the training proposed here.



Expansion to the rest of the Northern Cape:

A Rational Drug Use Training Workshop is proposed workshop for clinical and pharmacy
staff of the Northern Cape in January 1999. Participants will be selected from:
• Regional pharmacists
• Regional nurse trainers
• Doctors: full-time public sector, community service (the workshop will be accredited
as Continuing Professional Development time- 2 hours)
• Dentists
• Nursing college training staff

Training will include:
An Introduction to the principles of prescribing.
This is based on the WHO production “The Guide to Good Prescribing” using the
framework . Concepts behind the Essential Drugs Programme will be discussed. The
advantages and disadvantages of standard therapeutic guidelines will be considered.
Clinical cases for review of prescribing practice will include common problems seen in
the Northern Cape:
• Tuberculosis and HIV
• Hypertension
• Diarrhoeal disease
• Diabetes mellitus
• Dental disease and HIV
• Lower respiratory tract disease
Collection and collation of drug use indictors
Why we need to monitor drug use. What information can be gleaned from this process
(using the results of the base-line Kalahari survey)? Practical session collecting
indicators followed by collation of the data and discussion of the lessons learnt.


                                                                                         12
Review of stock management.
Review of the present system of stock management in the Northern Cape. Problems that
have been encountered will be discussed and solutions discussed. Presentation of a
simple stock management system for clinics using a tally sheet.

Referral systems.
This module will comprise a multidisciplinary discussion on the referral system in the
Northern Cape. How can this be streamlined and improved? How to provide clinics with
special hospital-prescribed medication?

Staff receiving this training are expected to train others in the important concepts after
the course. They will also be expected to collect or assist in collecting drug use
indicators for their region.



Conclusion:

The first year of rational drug use work in the Kalahari region has been very fruitful. Not
all of the goals set in the early part of the year were achieved. However, none of them
have been forgotten. In 1999 focus will shift from the drug use indicator collection (which
will require less input the second time round) to the training of clinic staff. Staff will
receive more input on the general approach to rational drug use, specific details on the
use of analgesics and antibiotics and emphasis will be placed on passing this knowledge
on to the patients.

The data presented here were presented to the Northern Cape Provincial Staff in
October 1998. It was favourably received and enthusiasm for implementing this work in
the whole province is high.




Contact details:
Dr Catherine Orrell, phone 021-406.6353, correll@uctgsh1.uct.ac.za
Mrs. Elna van der Walt, phone 05373-30044, elna@krp.up.healthlink.org.za
Matron Vienna Manong, phone 05373-30776, vienna@krp.up.healthlink.org.za




                                                                                             13
Appendix:

Indicators for the whole facility:
Please circle the number next to your answer. This is NOT a score, only a way of
differentiating the answers.

1) Type of facility (circle the number):
       3        District Hospital OPD
       2        Community Health Centre
       1        Clinic
       0        Mobile clinic

2) Number of patients seen at the facility per day?

3) Number of workdays in a year?

4) Degree of access to a Section 38a nursing sister:
       3      at the clinic daily
       2      weekly visits
       1      monthly visits
       0      visits less than monthly

5) Degree of access to a pharmacist:
       3      at the clinic daily
       2      weekly visits
       1      monthly visits
       0      visits less than monthly/never

6) Degree of access to a doctor:
       3      at the clinic daily
       2      weekly visits
       1      monthly visits
       0      visits less than monthly/never

7) Predominant source of medicines:
       3     Regional Hospital services
       2     State supplies
       1     From the manufacturers directly
       0     Donations

8) Do you have immediate access (i.e. can be obtained from within the facility and can
be used within a few minutes) to an unbiased source of drug information?
       1       yes
       0       no

Unbiased sources of drug information include the South African Medicines Formulary,
the Medunsa Primary Health Care Formulary or other reference textbooks. They do NOT
include any potentially biased information produced by a pharmaceutical company e.g.
MIMs.


                                                                                         14
9) Do you have immediate access to Standard Treatment Guide-lines (STGs)?
        1       yes
        0       no
These may be local, district or national guide-lines.
10) Is there a copy of the South African National Essential Drugs List immediately
available?
        1       yes
        0       no

11) Annual budget for medicines in Rands?

12) Source of the information provided in questions 7 and 11?
       3       available from the facility itself
       2       within the same district
       1       within the same province
       0       outside the province/not available

13) Number of key drugs available for use (see list below, check in the dispensary for
qu. 13-15):

14) Number of key drugs used before expiry date:

15) Number of key drugs stored correctly:

List of key drugs:
         oral rehydration fluid
         cotrimoxazole tablets
         procaine penicillin injection
         paediatric paracetamol syrup
         hydrochlorothiazide tablets
         ferrous salts and folic acid
         mebendazole tablets
         tetracycline eye ointment
         benzoic acid and salicylic acid ointment
         salbutamol inhaler

16) In general, how do the staff at your facility feel about their knowledge of medicines?
        3      knowledge is excellent
        2      good, feel safe treating a patient
        1      poor, needs to be improved
        0      non-existent

17) How do the staff feel about the access they have to drug information
(references/textbooks/by phone or e-mail)?
        3      access is excellent
        2      good, feel information is available when needed
        1      poor, access needs to be improved
        0      not accessible at all

18) Do your staff feel supported in the implementation of the EDP?


                                                                                         15
       3       yes, support is excellent
       2       good, feel support is available
       1       poor, support needs to be improved
       0       no support at all


TWO: Indicators for each prescription:
This will be collected on a separate form for EACH prescription i.e. one per patient.
Please circle the number next to your answer. This is NOT a score, only a way of
differentiating the answers.

1) What is the diagnosis given?

2) Is the name of the patient on the script?
        1      yes
        0      no

3) Does the signature of the prescriber appear?
       1       yes
       0       no

4) The number of drugs prescribed:

5) Number of prescribed drugs that are on the EDL:

6) Number of drugs that have been prescribed by their generic name:

7) Is the prescription in accordance with the STGs for that diagnosis?
        3       Yes
        2       almost all points coincide
        1       some points coincide
        0       not at all

8) Number of drugs prescribed that were actually dispensed:

9) Total cost of dispensed medication:

10) Did the patient have an adequate knowledge of dosage instructions: ( Patient should
know ALL of the following: how much, how often and for how long to take their
medication, as well as common side-effects e.g. "I must take amoxil, one capsule three
times a day for five days and it may make me have loose stools.").
       3       knowledge was good (all 4 points known)
       2       Knowledge was reasonable (knew 2 or 3 points)
       1       Little knowledge (knew one point only)
       0       did not have any knowledge of the instructions.




                                                                                        16
Indicators for each drug:
Please record the names of all the medications prescribed (as written), their strength,
dose and the duration of treatment. (From this we can work out the costs required
above.) NB: The labelling information that is written in line 1 of the second table, should
correspond with the drug that is written in line 1 of the first table.

Name of medication:       Strength of            Dose of medication:           Duration of
                          medication:                                          treatment:
       Amoxil             250 mg                  PO, 6 hourly                 10 days
1
2
3
4
5
6
7
8
9
10
Indicate whether the following information is written on the label of each of the drugs
dispensed. Use the same order as above.
       Patient name:      Drug name:              Dosing instructions:        Expiry date of drug:
e.g. no                   yes                     yes                         yes
1
2
3
4
5
6
7
8
9
10




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