QUALITY OF PRESCRIPTIONS IN PRIMARY CARE: WE NEED TO TARGET THAT QUALIDADE DAS PRESCRIÇÕES NA ATENÇÃO PRIMÁRIA: PRECISAMOS FALAR

Aim: To identify errors in drug prescriptions and its causes in a primary healthcare center. Method: Cross-sectional study carried out in a primary healthcare center in northeastern Brazil. A total of 707 drug prescriptions were analyzed using an instrument with pre-established criteria, according to the country's legal provisions regarding drug prescription. An Ishikawa diagram was created to identify the possible causes for the identified errors. Results: A total of 138 drug prescriptions (19.5%) presented information failure or inadequacy. From the errors found, 116 (16.41%) were related to information on dosage. The Ishikawa diagram showed opportunity for improvement in management, training, and technical/professional qualification. Conclusion: The errors seen on drug prescriptions at a primary healthcare center were related to illegibility, absence of dosage, and absence of mandatory patient information. Organizational, technical, scientific, and political factors were identified as the roots of the identified errors.


INTRODUCTION
Concerns about the quality of services offered in healthcare facilities have been widely discussed, mainly due to the alarming rates of adverse events that cause harm to patients at different healthcare levels (1)(2) .
There is a contemporary trend in a worldwide discussion on patient safety. In Brazil, public healthcare is provided by the Unified Health System (SUS in Portuguese), which offers universal access to integral care by means of a national health. There is an increasing concern about patient safety and care quality in facilities in the SUS system due to society's dissatisfaction with bad practices of care offered in such facilities (3)(4)(5) . Despite the widespread dissemination of patient safety studies developed in the hospital environment, it is known that there are gaps regarding this theme in primary healthcare centers or facilities (4,6) .
Medication errors affect care in a very dangerous way, generate unnecessary costs, extend the duration of treatments and the patients' length of stay, and can lead to litigious actions (7)(8) . This can result in discrediting of the professionals' performance and of the institutions involved. It is also known that safe behaviors are associated with the reduction of adverse events (2,(9)(10) .
In view of the relevance of the theme, this study aimed to identify errors in drug prescriptions and its causes in a primary healthcare center, taking into account the country's legal provisions regarding drug prescription.

MATERIAL AND METHODS
A cross-sectional study was developed in a primary healthcare center in northeastern     search for tactics to be used to prevent adverse events (11) .
In this scenario, there is a need to identify the causal factors involving medication prescription errors. The occurrence of these errors is directly related to the technical quality of the prescription, mainly with its legibility and completeness (12) .  (13)(14)(15) .
In addition to identifying weaknesses present in the stage of prescribing, it is essential to adopt safety models, some in the form of assistance protocols, in order to make the production of care and communication a systematic and equally knowledgeable act (16) .
With regard to the medication process, all REVIEW ARTICLE stages are of unparallel importance, however the prescription itself deserves special attention considering that it can be compared to a generating mechanism and guiding commands, which will lead "what", "how", "where", "when", and on "whom" interventions will be carried out (17)(18) .
In this study, the legibility criterion was established when observable words or expressions were written in an understandable way, allowing a clear understanding of the prescription without the need for deduction or supposition. It is known that people are more likely to use deductions when they read a prescription with a bad handwriting. This form of decoding (using purely deductive reasoning) carries with it a degree of imprecision with harmful repercussions (19) .
Bad handwriting and the existence of incomplete information are factors that predispose to harmful medication errors (20)(21) .
When considering a significance level of 5%, the comparison made using the chisquare test between the two categories of prescribing professionals in relation to legibility, quality of information, and presence of the patient's name and dosage showed that the physicians were more likely to make mistakes.
According to the study findings, 138 prescriptions (approximately 20%) had some abbreviation or acronym. The inappropriate use of acronyms and the non-standardization of the nomenclature of medicines also lead to difficulties in the understanding of prescriptions (14) . These difficulties can be associated with the massive variety of drugs currently available on the market, linked to the fact that many of them have very similar trade names (16,22) .
The use of abbreviations, a widely adopted practice by health professionals, can lead to confusing or misinterpretations (18,23) .
In Brazilian primary healthcare services, drugs are obtained in the same center were consultations are carried out, but patients are free to purchase them via commercial channels. Depending on the service, the form of acquisition of medications, or even by professionals' convenience, prescriptions can be interpreted dubiously. This can be made worse if the handwriting is hard to be read (1)(2)4) .
The use of abbreviations needs to be avoided as much as possible, especially in primary healthcare services in which patients leave the center carrying out the prescriptions.
An acronym may be usual for a health professional but may not be clear and known to the patient. Thus, professionals should avoid abbreviating information about the pharmaceutical form to be used, the route of administration, doses, quantities, and intervals of intake (8,12,24) . A study carried out in primary healthcare services in Sweden,  (25) .
One of the foundations of the safety culture is the adequate identification of the patient at all times, and in the case of assistance provided by primary care services (in which the patient takes the prescription with him to his home), this is even more important (26)(27) . Frequently, there is more than one person in Brazilian homes being treated for chronic or degenerative diseases. Arterial hypertension, for example, has extremely different pharmacological therapies. In the present study, the patient's name was missing in 31 prescriptions. The correct identification of the patient is essential for the implementation of a duly safe assistance (14)(15)(27)(28) .

Ishikawa diagram
Regarding the Ishikawa diagram, the Personal factors category included the main causes that compromised patient safety, such as personal training, excess of selfconfidence, haste/automatism, and finally, insufficient knowledge. Professional training is an attitude to be performed by everyone who enters a specific type of service, combined with permanent education (14) . Selfconfidence combined with automatism in the performance of functions enhances the probability of errors (29) .
In the following category, Organizational factors, we pointed out the lack of supervision, failures in communication (illegible handwriting), and the absence of protocols or flowcharts for prescription. For a safe practice, it is necessary to use and implement protocols that support the work routine (19,(29)(30) .
In the third category, External factors, the absence of a permanent evaluation policy and the containment of expenses were evidenced. External evaluation and monitoring policy are important tools for maintaining a minimum acceptable standard (15)(16) . This policy must involve analyzes of compliance with conducts.
In category No. 4, Patient factors, medication culture and hastiness were listed.
The fifth category, Work/environment factors, workload, the absence of auditing, and the inadequacy of the size of the pharmacy room were the root causes for the prescribing errors (30) . The existence of quality standards in the provision of care depends on periodic inspections and an audit policy (12) . Clinical audits, for example, work as a systematic analysis of clinical procedures aimed at improving the quality and results of care. In addition, the existence of regulatory inspections is important to control and verify procedures, observing if they are in compliance with all legal requirements (9,12,31) .
Professionals must understand the importance of audits and the adherence to protocols as a way to ensure patient safety and quality of care (9,18) .

Limitations
The main limitation of this study concerns the relatively small number of healthcare workers who were able to participate. Some professionals were interested in participate but were not available due to their busy schedule and this factor, particularly for physicians, might have limited our findings. This study is also limited by the use of only one primary healthcare unit.

Implications
Through the use of the Ishikawa diagram we were able to ascertain which were the most likely causal factors for the occurrence of prescription errors at a primary healthcare center, and also in the identification of needs for improvements in management, professional training/improvement, use of resources, and ongoing training of the health teams.

CONCLUSIONS
The study made it possible to assess