Slide 1

As one of JCAHO’s National Patient Safety Goals, we will be reviewing look-alike, sound-alike medication errors in an attempt to prevent mistakes involving the interchange of these drugs. Not only are there tons of drugs out on the market, each drug may have at least two names, a generic name, and a trade name. On top of the fact that there are so many medication names, there are many lines of communication and many hands involved in the process of administering medications to our patients. These factors along with many others make it imperative to increase awareness of this topic as well as invent ways to help prevent these errors.

Slide 2

Slide 3

When we think of look-alike sound-alike medication errors, we often just think of medication names that look alike when written or sound-alike when spoken. However, confusing packaging and labeling falls into this category as well because so many drug manufacturers are making their packaging so similar in an attempt to cut costs.

*ASHP: American Society of Health-System Pharmacist

Slide 4

It may surprise you that packaging or labeling confusion compose more medication errors than drug name confusion. There are two places this can easily happen. The first is the pharmacy, where the orders are filled. When the incoming stock is put away in the pharmacy, if one is not paying close enough attention, look-alike packaging may be put away in the wrong spot. So when someone goes to fill an order and grabs the drug off the shelf where it is always located, you can easily see where a look-alike packaging error may take place. The same goes for the patient’s med drawer that nurses use. Due to similar packaging or labeling, it is easy to make a mistake when administering medication to the patient.

Slide 5

In some ways, administering medication to a patient can be similar to playing the game “telephone”, where everyone tries to correctly interpret the original order. The physician can order a medication by writing it down in the orders section of the chart, giving a verbal order to a nurse, or calling the order to the pharmacy. The pharmacist then takes the order, interprets it, types the label, the technician fills the order, the pharmacist checks the order, and dispenses it. The nurse either hangs the IV bag the pharmacy sent up or gets the medication out of the patient’s medication drawer. Since there are several steps and several people involved between the physician’s verbal or written order to the time the patient receives the medication, there are many places to err with look-alike sound-alike medications.

Slide 6

The drug names of these two products definitely look alike and can easily be confused when reading a physician’s order or the patient’s medication list on the computer. The drug manufacturer recently changed the look of the packaging of the two products as shown here, which helps reduce errors, but the drug names are so close that errors may still occur.

Slide 7

Famotidine and Furosemide have often been confused. The name is similar and can easily be confused when spoken, written or even typed. Also contributing to error is the fact that both tablets are often small, white, and round, and are both often administered twice daily.

Slide 8

In this case, the nurse caught the error before administering the drug to the patient. It was a fortunate catch as the patient had a peanut allergy and there have been case reports of anaphylaxis to Atrovent MDIs in patients with peanut allergies.

Video 1

The following is an example of how not to take a telephone order. What mistakes do you notice? Feel free to leave comments as to what was done wrong.

Slide 9

Now that you know what a look-alike or sound-alike medication error is, let’s go over some strategies to recognize and prevent them from occurring.

Slide 10

• For starters, it is important to familiarize yourself with the hospital formulary. As you will see these drugs the most frequently, you should be aware which medications have the potential to be mistaken for one other.


• From time to time, review look-alike/sound-alike drug resources. There are a variety of organizations who publish extensive lists to identify which medications are most likely to cause these problems.


• Look-alike/sound-alike errors can result with any of a drug’s numerous names. This is why on medication profiles both the brand and generic names are listed for each medication.


• Have confidence in your own drug knowledge. If you can remember what a medication is used for or what a usual dose might be, this goes a long way in preventing medication errors of all kinds, not just the look-alike/sound-alike kind. If you think something looks fishy, it probably is.

Slide 11

• Another measure to stop these errors is known as TALLman lettering. Drugs with similar looking or sounding names will be listed on med profiles with capitalized letters accentuating the part of that name which is unique. If you see a medication with TALLman lettering, take note that it could be confused with another drug and use caution.


• Packaging plays a role in look-alike drugs. Do not pull a drug based on its package alone and make sure to look at a medication’s container before administering.


• There's more to the appearance of a medication than just the packaging. Prior to giving a drug, look at the contents themselves. The shape of a tablet or color of a solution can be a indicator if you have the right drug.


• As a nurse, you are the last line of defense against a medication error, so double check the drug name, the packaging, the route, the interval, the dose, and the patient. Again, if anything looks out of place, notify the charge nurse, a physician, or the pharmacy department.

Slide 12

• If you are in a rush, you may misread a medication and assume it is a different drug. A large portion of medication errors can be avoided if health professionals pay attention and simply take their time.


• Clarification is very important to ensure the right drug gets to the right patient. If you are receiving a verbal or telephone order, repeat back the medication, dose, route, frequency, and, if possible, what it is to be used for. If you are unsure of what the order is, ask to have the medication spelled out to avoid any confusion.


• The same rules apply for written orders. If a drug name is poorly transcribed, it is better to take the time to make certain what medication is required.


• Educating coworkers is another step towards accurate administration. If you recognized a potential look-alike or sound-alike error, one of your fellow nurses could mistake the same drug too.


• And finally, remember that no one is flawless. The pharmacists, physicians, and nursing staff are all at risk of making a medication error. We are all human, after all, but by taking these strategies into consideration, we can greatly reduce the potential for look-alike/sound-alike errors.

Slide 13

In both of these examples, neither medication was dispensed or administered, but they were entered into the computer incorrectly. It is fairly easy to see how one would be confused with such similar looking names. Of course, similar names do not mean similar indications. Zetia is used to lower cholesterol while Zebeta decreases blood pressure. And Metoprolol has two formulations, one that is dosed once daily and another that is twice daily.

Slide 14

These next examples involved dispensing and both could have been either a look-alike or a sound-alike error. In the top scenario, it is quite clear there is a difference between the drugs when taking into account the appearance of the tablets themselves. As for the bottom case, these meds look very similar, but it was a nurse who caught the mistake, not the pharmacy.

Slide 15

These are some resources you may find helpful if you would like to know more about look-alike/sound-alike medication errors. All three of these organizations work to keep an up-to-date database on potential mishaps. Feel free to peruse their lists, but fair warning, they can be a bit overwhelming.

Slide 16

The following is a list of the most common look-alike/sound-alike medication pairs at Spectrum Health. They are NOT ranked in order of prevalence. Here are the measures in place to prevent such errors.


1.TALLman lettering, segregated storage, verbal/telephone orders disallowed, prepared and administered only by chemotherapy staff, and a variety of double checks.


2.TALLman lettering and segregated storage.


3.Segregated storage, LASA pop up alerts in Cerner and Pyxis, and double checks.

Slide 17

4. Different size containers, segregated storage, TALLman lettering, pop up alert in pyxis, and double checks.


5. Pen devices, “u” abbreviation disallowed, blood glucose monitoring, hypoglycemia protocol, and double checks.


6. Segregated storage and TALLman lettering.

Slide 18

7. Segregated storage and pop up alerts.


8. Segregated storage and TALLman lettering.


9. Segregated storage, daily orders required for warfarin, and vitamin K protocol.

Slide 19

What is the error here??

Answer:

LASA

This happened on 6 south and was caught before given. Although it is the same medication, what could be the consequences of giving it in an alternate route?

Slide 20

A typical medication profile found in Cerner with a variety of measures to prevent LASA errors.

Video 2

In this video, we see the proper protocol for taking a telephone order. What are some of the correct steps that were taken? Again, comments are encouraged.



After watching the video, please click on the assessment link at the top to test your knowledge and to receive credit for this assignment.