Rational Prescribing Under Pressure: A World Health Organization Indicator and National Medical Commission Compliance Audit With Shift-Based Analysis of Emergency Prescriptions at a Tertiary Care Hospital in North India

Background: Rational prescribing is essential for patient safety and cost-effective healthcare. Good prescription writing is important from a treatment, documentation, and medico-legal point of view. The World Health Organization (WHO) prescribing indicators and the National Medical Commission (NMC) guidelines provide standardized benchmarks to evaluate and monitor prescription quality. However, these are mainly applicable to outpatient department (OPD) setups. The high patient volumes, time constraints, and high-pressure, resource-limited environment might alter doctors' prescribing behavior in emergency settings, particularly in developing countries. Objectives: This study aims to evaluate prescribing practices in a government emergency department using WHO core prescribing indicators and assess prescription completeness against NMC standards. A secondary objective was to evaluate shift-based variation in prescribing quality. Methods: This retrospective cross-sectional study analyzed 648 prescriptions collected over one year as part of a quality improvement initiative. WHO prescribing indicators, NMC compliance parameters, and prescription completeness metrics were assessed. Statistical analysis included non-parametric tests, chi-square tests, and multivariate regression models. Results: A total of 1719 drugs were prescribed, with a mean of 2.65 drugs per prescription. Of these, 1115 (64.9%) were prescribed by generic name, and 1500 (87.6%) adhered to the National List of Essential Medicines (NLEM). Antibiotics were prescribed in 42 (6.5%) prescriptions, whereas injections were used in 585 (90.3%) prescriptions. Documentation gaps were significant, with diagnosis recorded in only 55 (8.5%) and complete prescriber identification in just 5 (0.8%) prescriptions. Only 21 (1.2%) drug entries met conventional completeness criteria; it improved to 960 (55.8%) after adjusting for stat-dose prescriptions. Shift-based analysis revealed a significant decline in diagnostic documentation from morning to night shifts, while vital recording remained relatively stable. After adjusting for age, gender, and total medications, night shift was independently associated with higher odds of injection use and lower odds of antibiotic prescribing as compared to morning. Older age and higher total medications were also independent predictors of injection use. Conclusion: Prescribing practices in the emergency department showed significant deviations from WHO indicators and NMC standards, particularly in documentation and injection use. While low antibiotic prescribing reflects cautious antimicrobial use, high injection rates and poor documentation highlight areas for improvement. Shift-based variation suggests an “off-hours effect” influencing clinical decision-making. Targeted interventions, including structured prescription formats, audit-based feedback, and shift-specific strategies, are needed to enhance prescribing quality and patient safety.