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Look-Alike and Sound-Alike Medications Practitioner Perspectives
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Transcript of Look-Alike and Sound-Alike Medications Practitioner Perspectives
Look-Alike and Sound-AlikeMedications
Practitioner Perspectives
Timothy Lesar, Pharm.D.Timothy Lesar, Pharm.D.
Director of PharmacyDirector of Pharmacy
Albany Medical CenterAlbany Medical Center
Albany, NY Albany, NY
Practitioner perspectives
Evidence base for commentsEvidence base for comments Drug product – medical care system Drug product – medical care system
interactions and risk for errorsinteractions and risk for errors Select examplesSelect examples Implications for risk reductionImplications for risk reduction Implications for safety enhancementsImplications for safety enhancements
Evidence base for comments Systematic error detection, assessment, categorization Systematic error detection, assessment, categorization
and recording at AMC (since 1987) (> 32,000 and recording at AMC (since 1987) (> 32,000 prescribing errors) prescribing errors)
Nature of errors and contributors identified Nature of errors and contributors identified > 20% related to drug names and nomenclature> 20% related to drug names and nomenclature
Lesar et al, JAMA 1990;263:2329-34Lesar et al, JAMA 1990;263:2329-34 Lesar, Ann Intern Med 1992;117:537-8Lesar, Ann Intern Med 1992;117:537-8 Lesar et al, Arch Intern Med 1997;157:1569-76Lesar et al, Arch Intern Med 1997;157:1569-76 Lesar et al, JAMA 1997;27:312-7Lesar et al, JAMA 1997;27:312-7 Lesar, Arch Pediatr Adolesc Med 1998;152:340-4 Lesar, Arch Pediatr Adolesc Med 1998;152:340-4 Purdy et al, Ann Pharmacother 2000;833-8Purdy et al, Ann Pharmacother 2000;833-8 Lesar, J Gen Intern Med 2002;17:579-87Lesar, J Gen Intern Med 2002;17:579-87 Lesar, Ann Pharmacother 2002;36:1833-9Lesar, Ann Pharmacother 2002;36:1833-9
0
50
100
150
200
250
300
350
1996 1997 1998 1999 2000
Err
ors
per
year
A GROWING PROBLEM:Number of dosage form related errors at AMC from
1996 to 2000 (> 75% related to nomenclature)
Emotional base for comments Drug names, nomenclature and packaging:Drug names, nomenclature and packaging:
Often have a clear potential for error Often have a clear potential for error Commonly cause or contribute to patient harm.Commonly cause or contribute to patient harm. Cause or contribute to Cause or contribute to 2 or more2 or more significant significant
medication errors medication errors every dayevery day at AMC at AMC PerceptionPerception that safety is not always primary that safety is not always primary
consideration in product naming. consideration in product naming. Simple product changes will reduce risk for error Simple product changes will reduce risk for error
and enhance overall safety!and enhance overall safety!
Conceptual Framework Drug product inserted into complex care environment.Drug product inserted into complex care environment. Drug product interacts with care environment and care Drug product interacts with care environment and care
processes in identifiable (often surprising) and predictable processes in identifiable (often surprising) and predictable fashion.fashion.
These interactions will be determined by specific product These interactions will be determined by specific product characteristics and specific care processes characteristics and specific care processes
Errors occur in predictable ways!Errors occur in predictable ways! Allows risk assessmentAllows risk assessment Allows risk reductionAllows risk reduction Allows error preventionAllows error prevention
Conceptual Framework Risk for error and ADERisk for error and ADE
Error producing conditionsError producing conditions Likelihood of error occurringLikelihood of error occurring Environment and processes of careEnvironment and processes of care Drug(s) involvedDrug(s) involved Patient characteristic(s)Patient characteristic(s) Nature and type of errorNature and type of error
Conceptual Framework Any or all characteristics of a drug product can increase Any or all characteristics of a drug product can increase
or decrease risk, and MUST be considered in risk or decrease risk, and MUST be considered in risk assessment:assessment: Generic name, brand nameGeneric name, brand name Dose, strength(s), dose form, packagingDose, strength(s), dose form, packaging Route, frequency, instructionsRoute, frequency, instructions Storage requirementsStorage requirements Indications, patient populationIndications, patient population Likely care environmentLikely care environment OtherOther
Conceptual Framework
The medical care “vortex”The medical care “vortex”
Drug productDrug product
ERRORERROR
Stress
Care Process
es
Brand names
Dose forms
Generic names
Doses
Routes
Communications
Labels
Symbols
Abbreviations
Legibility
Human
factorsStorage
UBC
Packaging
Computers
Culture
Marketing
Workconditio
n
Fatigue
Language
SuffixesCombo
product
Patient
Indication
CareSettin
g
Preparation
Purchasing
New /Changed Product
OrProcess
Task
Team
NomenclatureDose
Regimens
Knowledge
ERRORS!
Selected Examples
Medication products in the Medication products in the medical care “vortex”medical care “vortex”
Predictable problems:Insulin brand names
Humulin “Log” ordered instead of Humulin-L (Lente).
Nurse thought Humalog” was to be given.
Names and labels:Novolog is “regular” (“R” )insulin, right?
Dosage form names: OxyContin and MSContin
Dosage form names:Just a matter of time……
0.5mg, 1mg, 2mg, 3mg tablets
XR
Legibility and drug names
Capoten or Cozaar?
Protonix or Protamine?
Unasyn or Vancomycin?
Technology-drug product interface:Levophed for Lopressor
Why dose, route, frequency and indication are important:
Tricor for Tracleer Error detected because dose was different
Error NOT detected because dose was the same
Proscar in a female??
Practitioner perspectives Implications for risk reduction and safety enhancements Predictable nature of errors allows risk assessment Predictable nature of errors allows risk assessment
and reduction. and reduction. Predictable nature of errors allows product design Predictable nature of errors allows product design
which can which can enhanceenhance safety. safety. All drug product characteristics must be All drug product characteristics must be
considered in risk assessment and prevention. considered in risk assessment and prevention. Care environment and processes must be Care environment and processes must be
considered in risk assessment and prevention.considered in risk assessment and prevention.
Practitioners perspective Summary
Drug names, labels and packaging are major Drug names, labels and packaging are major contributors to medication errorscontributors to medication errors
Risk for error is determined by both drug product Risk for error is determined by both drug product characteristics and the care system processes.characteristics and the care system processes.
Risk assessment must include multiple drug Risk assessment must include multiple drug characteristics (not just names)characteristics (not just names)
Risk of error within care system often readily apparent Risk of error within care system often readily apparent The predictable nature of errors provides opportunity The predictable nature of errors provides opportunity
for product naming and design which reduces risk and for product naming and design which reduces risk and enhancesenhances safety. safety.