I t is not surprising that many drug names

sound and look alike. Frontline colleagues

may easily be confused with unclear hand-

written prescriptions because of the

similarity in name or appearance. It is one of

the most common causes of medication error

and is of concern worldwide.

Contributing factors to confusion:

● Illegible handwriting

● Incomplete knowledge of drug names

● Newly available products

● Similar packaging or labeling

● Similar clinical use

● Similar strengths, dosage

forms, frequency of

administration

Use of TALL man lettering for look-alike

drug names:

“Tall man” lettering is a method for

differentiating the unique letter characters

of similar drug names known to have been

confused with one another. Highlighting a

unique portion of a drug name with upper

case letters can draw attention to the

dissimilarities between look-alike drug

names, making them less prone to mix-up.

In US, several studies

have shown that the

utilization of tall

man lettering is

effective in reducing

errors caused by

look-alike names.

Look-alike & Sound-alike (LASA) Medication Names

Vol. 2

July 2011

Sharing of good prac-

tices to manage LASA

drugs

P.2

Sharing of potential risk

found in HA hospitals -

Similar packing of

500ml dextrose IV infu-

sion bottles: D5 vs D50

P.3

Test your knowledge -

abbreviations used in

prescription

P.3

Sharing of globally

reported medication

errors - FDA alert on

confusion between

Risperidone

(Risperdal®

) &

Ropinirole (Requip®

)

P.4

“High Alert Medica-

tions” to replace “High

Risk Medications”

P.4

Answers to the test P.4

Inside this issue: Standardization of TALL man lettering for LASA names

A s one of the difficulties with the use of

tall man letters include inconsistent

application in hospitals and lack of

standardization regarding which name pairs

to include as well as which letters to be in

uppercase, the HA Medication Safety

Committee (MSC) has compiled and stan-

dardized 11 sets of generic drug names. This

list has made reference to both the overseas

recommendations and locally reported mix-

up drug names. Colleagues are advised to

standardize and apply the TALL man letters

to the labeling of drug storage locations such

as drug shelves at pharmacy and drug cup-

boards in wards. The tall man parts are

preferably in bold and colored letters for

more prominent illustration.

MSC will review and update the list annually.

Colleagues are recommended to be vigilant

on any potential risky pairs and feedback to

MSC via cluster representatives for

consideration.

Announcement :

- In order to enrich the

educational content

related to medication

safety, the sharing on

medication incidents

and consolidated

statistics will be

published in HA Risk

Alert (HARA).

- This bulletin will be

published half-yearly in

November and May from

next issue onwards.

Next Issue:

November 2011 Medication Safety Bulletin

Page 2 Medication Safety Bulletin

Sharing of good practices to manage LASA drugs

M SC had been conducting hospital visits to different hospitals since Feb 2009 and the first

round visit of 7 clusters had been completed. During the hospital visits, MSC observed many

good practices undertaken by hospitals to enhance medication safety, some of which are effective

in tackling problems caused by similar drug packing or drug names.

Prompting of LASA warning in pharmacy system

— CARS (by item endorsement function)

E.g. An alert box of “LASA Warning: amloDIPINE” is

prompted whenever the item code “AMLO01” is

entered into the CARS

Use of “LASA drug” alert labels during dispensing

Use of TALL man letters when labeling at

pharmacy and in ward

Reminder on drug shelf to check the drug label

Separation of drug storage for different strength

products/ LASA drugs

LASA/ Medication Safety Notice Board

- To alert colleagues on LASA drugs and drugs with

appearance changed recently

L abels of various strengths and volumes of dextrose IV infusion bottles (i.e. D5, D20 and D50) supplied by a

drug company have been changing in phases since May 2010. Subsequent to the change, a number of medica-

tion incidents and near misses have been reported in hospitals recently due to mix-up of D5 and D50 preparations.

Recommendations:

1. Avoid keeping both strengths (5% and 50%) with the same volume as ward stock. Review the ward stock list

and consider replacing the 500ml D50 with 20ml D50 if possible.

2. Separate the storage of similar packing bottles at pharmacy and in ward. Place a warning labels to remind

staff to be vigilant when picking these items.

3. Educate and alert staff the importance of medication safety related to label design and label change.

Page 3

Sharing of potential risk found in HA hospitals

- Similar packing of 500ml dextrose IV infusion bottles : D5 vs D50

NEW packing labels — 500ml Dextrose 5% vs 500ml Dextrose 50%

Education poster on new product labels provided by the drug company

Test your knowledge - abbreviations used in prescription Q1: What does “mane” stand for?

Q2: Can you differentiate among “qid, qod, qds and qd”?

Q3: Which of the above abbreviation(s) is(are) not allowed to be used in HA (Answers are at the back of this page)

H igh risk medications are medications that have the highest risk of causing injury when misused. Errors with

these products are not necessarily more common, but the consequences are clearly more devastating.

In order to align with the term used in overseas countries, the term “High Alert Medications” would be used in the

future communications instead of the term “High Risk Medications”.

Page 4 Medication Safety Bulletin

This Bulletin is prepared by the Chief Pharmacist’s Office, HAHO

R ecently, FDA evaluated the medication errors relating to

the confusion between risperidone (Risperdal® ) and ropini-

role (Requip® ) obtained from their Adverse Event Reporting

System database. In some cases, patients who took the wrong

medication resulted in adverse events and were hospitalized. Ad-

verse events resulting from administering wrong medication in-

cluded confusion, lethargy, ataxia, hallucinations, tiredness, diz-

ziness, tingling, numbness and altered mental status.

Possible factors to the confusion:

1. Similarities of both the brand and generic names

2. Illegible handwriting on prescription

3. Overlapping product characteristics, such as the drug strengths, dosage forms, and dosing intervals

4. Similarities of the container labels and carton packaging (for generic products by the same manufacturer)

Recommendations:

1. Prescribers to write/ print the drug name clearly on the prescription/ MAR

2. Pharmacists to confirm/ clarify the drug name with the prescribers if the prescription is not legible

3. Pharmacy staff to physically separate the stocks of these two drugs on the shelf

4. Pharmacists to counsel patients about the prescribed medication, make sure patient understands the

purpose of taking the medication to avoid prescribing/ dispensing incorrect medication

Sharing of globally reported medication errors

- FDA alert on confusion between Risperidone (Risperdal® ) & Ropinirole (Requip® )

“High Alert Medications” to replace “High Risk Medications”

1. Concentrated electrolytes

2. Cytotoxic

chemotherapy

3. Drugs commonly associated with drug allergies e.g. Penicillin, aspirin,

NSAIDs 4. Vasopressors

& inotropes

5. Anticoagulants including heparin

6. Neuromuscular blocking agents

7. Oral

hypoglycaemics 8. Insulins

9. Narcotics/ opioids High “Alert” Medications

Answers Abbreviation Intended meaning Possible confusion Recommendations

Q1: mane In the morning Tomorrow morning

Q2: qid/ qds Four times a day qds can be mistaken as qd Use qid instead of qds

qod Every other day q.d. (daily) Spell out “every other day”

qd daily qod or qds Spell out “daily”

Q3: “qod” and “qd” are not allowed to be used in HA (refer to HA “Do Not Use” list)