AHRQ Patient Safety Network

The Collection > Look-Alike, Sound-Alike Drugs

PATIENT SAFETY PRIMERS
Medication Errors

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Look-Alike, Sound-Alike Drugs

Origin/Sponsor

•Australia and New Zealand (2)

Resource Types

•Journal Article (52)

•Newspaper/Magazine Article (22)

•Press Release/Announcement (7)

•Special or Theme Issue (1)

•Tools/Toolkit (3)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (8)

•Active Errors (40)

•Latent Errors (13)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (31)

•Legal and Policy Approaches (9)

•Error Reporting and Analysis (24)

•Communication Improvement (25)

•Human Factors Engineering (31)

•Specialization of Care (3)

•Logistical Approaches (7)

•Culture of Safety (5)

•Technologic Approaches (28)

•Education and Training (17)

Clinical Areas

•Medicine (38)

•Nursing (7)

•Pharmacy (59)

Target Audience

•Health Care Providers (86)

•Health Care Executives and Administrators (52)

•Non-Health Care Professionals (12)

•Patients (15)

Setting of Care

•Hospitals (33)

•Residential Facilities (2)

•Ambulatory Care (15)

•Outpatient Surgery (1)

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COMMENTARY

Miscalculated Risk

Strassels SA. AHRQ WebM&M [serial online]. August 2006.

COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

A Troubling Amine

Flynn EA. AHRQ WebM&M [serial online]. September 2006.

PRESS RELEASE/ANNOUNCEMENT

Heparin sodium injection 10,000 units/mL, and HEP-LOCK U/P 10 units/mL medication errors.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 6, 2007.

AUDIOVISUAL

Preventing fatal heparin overdoses.

Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.

COMMENTARY

XL or Smaller?

Kozer E. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:844-847.

PRESS RELEASE/ANNOUNCEMENT

Consumers Filling U.S. Prescriptions Abroad May Get the Wrong Active Ingredient Because of Confusing Drug Names.

FDA Public Health Advisory [US Food and Drug Administration Web site]. January 2006.

COMMENTARY

The 2-Week Itch.

Cohen MR. AHRQ WebM&M [serial online]. April 2003.

NEWSPAPER/MAGAZINE ARTICLE

Generic drug names: fertile ground for errors?

Wynn P. Drug Topics Supplements. August 8, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

PA-PSRS Patient Saf Advis. December 2005;2:29-31.

STUDY

Ability of practitioners to identify solid oral dosage tablets.

Schiff GD, Kim S, Seger AC, Bult J, Bates DW. Am J Health Syst Pharm. 2006;63:838-843.

NEWSPAPER/MAGAZINE ARTICLE

Buying the wrong medicine overseas.

Chase M. Wall Street Journal. August 16, 2005:D1.

COMMENTARY

Medication safety: look-alike/sound-alike drugs in home care.

Friedman MM. Home Healthc Nurse. 2005;23:243-253.

NEWSPAPER/MAGAZINE ARTICLE

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011;16:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Use of tall man letters is gaining wide acceptance.

ISMP Medication Safety Alert! Acute Care Edition. July 31, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Drug name confusion: preventing medication errors.

Rados C. FDA Consum. 2005;39:35-37.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:445-448.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:114-117.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

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