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 (45)

•Newspaper/Magazine Article (16)

•Press Release/Announcement (8)

•Special or Theme Issue (1)

•Tools/Toolkit (3)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (7)

•Active Errors (35)

•Latent Errors (11)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (26)

•Legal and Policy Approaches (8)

•Error Reporting and Analysis (24)

•Communication Improvement (21)

•Human Factors Engineering (23)

•Specialization of Care (2)

•Logistical Approaches (5)

•Culture of Safety (6)

•Technologic Approaches (23)

•Education and Training (16)

Clinical Areas

•Medicine (38)

•Nursing (6)

•Pharmacy (50)

Target Audience

•Health Care Providers (78)

•Health Care Executives and Administrators (50)

•Non-Health Care Professionals (12)

•Patients (11)

Setting of Care

•Hospitals (31)

•Residential Facilities (2)

•Ambulatory Care (10)

•Outpatient Surgery (1)

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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.

COMMENTARY

Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant.

Mannan K, Chow P, Lissauer T, Godambe S. Acta Paediatr. 2007;96:1536-1567.

COMMENTARY

ISMP medication error report analysis.

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

PRESS RELEASE/ANNOUNCEMENT

Edetate Disodium (marketed as Endrate and generic products).

FDA Public Health Advisory [US Food and Drug Administration Web site]. January 16, 2008.

COMMENTARY

Caution, Interrupted.

Wears RL. AHRQ WebM&M [serial online]. September 2004.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:288-292.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:556-557.

NEWSPAPER/MAGAZINE ARTICLE

Sterile water should not be given "freely."

PA-PSRS Patient Saf Advis. June 2008;5:53-56.

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

COMMENTARY

Discharge Fumbles.

Forster A. AHRQ WebM&M [serial online]. December 2004.

COMMENTARY

The Wrong Shot: Error Disclosure.

Gallagher TH, Levinson W. AHRQ WebM&M [serial online]. June 2004.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

COMMENTARY

ISMP medication error report analysis.

Cohen M. Hosp Pharm. 2006;41:222-224.

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.

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

200 epidural blunders admitted after three women die.

Oakeshott I. The Sunday Times. June 18, 2006.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:937-938, 945.

BOOK/REPORT

MEDMARX Data Report: A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine's Call to Action (2003-2006 Findings and Trends 2002-2006).

Rockville, MD: United States Pharmacopeia; 2008.

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