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Search results for "United States of America"

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Journal Article > Study

Automated detection of look-alike/sound-alike medication errors.

Rash-Foanio C, Galanter W, Bryson M, et al. Am J Health Syst Pharm. 2017;74:521-527.

Look-alike and sound-alike medications increase the risk of adverse drug events. This retrospective study found that look-alike and sound-alike medications can be identified in an automated fashion by comparing a medication and its known look-alike and sound-alike medications to diagnostic codes at the point of computerized provider order entry. This is a promising strategy for preventing this type of prescribing error.

Legislation/Regulation > Multi-use Website

National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; 2017.

The National Patient Safety Goals (NPSGs) have become a critical method by which The Joint Commission promotes and enforces major changes in patient safety. The criteria used for determining the value of these goals, and required revisions to them, are based on the merit of their impact, cost, and effectiveness. Recent changes have focused on preventing hospital-acquired infections and medication errors, in addition to existing goals promoting surgical safety, correct patient identification, communication between staff, and identifying patients at risk for suicide. In 2014, the group added improving the safety of hospital alarm systems, with a plan for a phased implementation of performance measures. For 2017, a new NPSG on catheter-associated urinary tract infections (CAUTI) will apply to nursing care centers, and the NPSGs on CAUTIs for hospitals and critical access hospitals have been revised to apply current evidence.

Tools/Toolkit > Fact Sheet/FAQs

FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters.

Institute for Safe Medication Practices. June 2016.

Mistakes associated with look-alike medication names are a safety concern in health care. Tall Man lettering is one recommended strategy to reduce confusion associated with similarities in drug names. This list includes medications recognized by clinicians and professional organizations as those suited for the application of Tall Man lettering to make their use safer.

Journal Article > Study

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.

Schroeder SR, Salomon MM, Galanter WL, et al. BMJ Qual Saf. 2017;26:395-407.

Look-alike and sound-alike drug names are a concerning source of confusion and medication errors. Although drug names currently undergo tests to assess their potential for confusion prior to approval, these tests have not reliably predicted real-world error rates. This study describes the development and validation of four drug name memory and perception laboratory tests. Eighty participants completed the tests and their results were analyzed against actual errors in two large outpatient pharmacy chains. The laboratory tests performed very well, demonstrating a strong association between drug name confusion errors seen during testing and those observed in real-world experience. The authors suggest that regulators and drug companies consider using these tests prior to approval of new drug names.

Newspaper/Magazine Article

Hospital discharge: it's one of the most dangerous periods for patients.

Rau J. Washington Post. April 29, 2016.

Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.

Newspaper/Magazine Article

Do not let "Depo-" medications be a depot for mistakes.

ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4.

Confusion due to look-alike and sound-alike medications are known to contribute to medication errors. Describing errors associated with a certain medication naming convention, this newsletter article offers recommendations to reduce risks related to these drugs, including labeling clarifications, storing medications separately, barcode scanning, and staff education.

Journal Article > Study

Tallman lettering as a strategy for differentiation in look-alike, sound-alike drug names: the role of familiarity in differentiating drug doppelgangers.

DeHenau C, Becker MW, Bello NM, Liu S, Bix L. Appl Ergon. 2016;52:77-84.

This study found that Tallman lettering—in which specific letters in drug names are printed in capital letters to avoid being mistaken for a look-alike or sound-alike medication—led to more effective detection of changes between drugs by health care professionals and consumers. A prior WebM&M commentary discussed Tallman lettering as one strategy for improving the safety of look-alike and sound-alike medications.

Journal Article > Study

Evaluating the potential severity of look-alike, sound-alike drug substitution errors in children.

Basco WT Jr, Garner SS, Ebeling M, Freeland KD, Hulsey TC, Simpson K. Acad Pediatr. 2016;16:183-191.

Look-alike, sound-alike drug names pose serious threats for potential medication errors. In this study, 38 pediatricians participated in a modified Delphi process to classify the clinical importance of more than 600 look-alike, sound-alike medication pairs that present risks to children.

Journal Article > Commentary

A method of addressing proprietary name similarity for US prescription drugs.

Stockbridge MD, Taylor K. Ther Innov Regul Sci. 2015;49:524-529.

Health care professionals can raise awareness of look-alike and sound-alike medication confusion by reporting mistakes when they occur in daily practice. This commentary provides information about the regulatory name assessment process to promote clinician reporting of problems associated with drug name similarity.

Newspaper/Magazine Article

Strengthen your resolve: no unlabeled containers anywhere, ever!

ISMP Medication Safety Alert! Acute Care Edition. November 6, 2014;19:1-4.

Despite the designation of proper labeling as a National Patient Safety Goal in 2006, the problem of unlabeled solutions and medications persists. This newsletter article outlines several incidents involving labeling issues that contributed to patient harm or death and provides strategies to reduce risks related to poor labeling practices, including ensuring labels are available in all settings that require them, using tall man lettering to differentiate look-alike drug names, and limiting access to solutions and medications.

Journal Article > Study

Indication alerts intercept drug name confusion errors during computerized entry of medication orders.

Galanter WL, Bryson ML, Falck S, et al. PLoS One. 2014;9:e101977.

Clinicians use thousands of prescription medications during routine care, and new medications are regularly incorporated into practice. Confusion between medications with names that appear or sound similar is a common cause of medication errors. This observational study sought to determine whether a computerized provider order entry system—with an alert that prompted providers to enter the indication when certain medications were ordered and required users to click "OK" to ignore the alert, to add the drug to a problem list, or to cancel the order—identified drug name confusion errors. These alerts intercepted 1.4 drug name confusion errors per 1000 alerts. While authors recommend that these alerts be implemented to decrease medication errors, they suggest narrowing the number of medications selected to prompt alerts to reduce risk of alert fatigue. A previous AHRQ WebM&M commentary describes an incident involving a look-alike drug error and reviews strategies to enhance safety of medication selection.

Journal Article > Review

Look alike/sound alike drugs: a literature review on causes and solutions.

Ciociano N, Bagnasco L. Int J Clin Pharm. 2014;36:233-242.

Clinicians use thousands of prescription medications during routine care, and new medications are regularly incorporated into practice. Consequently, confusion between medications with names that appear or sound similar is a major source of medication errors. The Institute for Safe Medication Practices (ISMP) maintains a list of look-alike and sound-alike drugs, and The Joint Commission mandates that hospitals have systems for preventing these errors as part of its National Patient Safety Goals. Despite awareness of the problem and mandates to address it, this systematic review found a lack of firm data on the incidence of these errors and minimal information regarding effective strategies to avoid them. Although it is plausible that computerized provider order entry should prevent sound-alike errors (which mostly arise from prescribing errors) and the ISMP recommends use of "tall man" lettering to avert look-alike errors, there is no data documenting the effectiveness of these interventions. A previous AHRQ WebM&M commentary discussed a look-alike drug error.

Press Release/Announcement

Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 6, 2013.

This announcement describes the risk of medication mix-ups associated with the use of an incorrect nonproprietary name for a breast cancer drug.

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.

This newsletter article reveals system failures that contribute to continued drug name confusion, even after authorities have been notified of the problem.

Press Release/Announcement

Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip).

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; June 13, 2011.

This notice raises awareness of a two look-alike/sound-alike drugs, one an antipsychotic medication and the other a dopamine agonist.

Newspaper/Magazine Article

Look-alike, sound-alike drugs trigger dangers.

Aleccia J. MSNBC.com; May 28, 2010.

This news piece details errors involving medication name confusion and presents tips for consumers to avoid such mistakes.

Journal Article > Commentary

ISMP medication error report analysis.

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

This monthly selection of error reports discusses incidents involving look-alike drug names, concentration dosage error, and harm related to abbreviation use.

Journal Article > Commentary

ISMP medication error report analysis.

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

This report discusses examples of serious medication errors involving "sound-alike" drugs as well as use of ambiguous abbreviations.

Journal Article > Study

Listen carefully: the risk of error in spoken medication orders.

Lambert BL, Dickey LW, Fisher WM, et al. Soc Sci Med. 2010;70:1599-1608.

This auditory perception study explored factors that led to erroneous verbal orders.

Press Release/Announcement

Maalox Total Relief and Maalox Liquid Products: Medication Use Errors.

MedWatch Safety Alert. Rockville, MD: US Food and Drug Administration; February 17, 2010.

This announcement alerts consumers and health care professionals to dangers associated with name confusion on a widely used over-the-counter medicine.

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