Jennifer Simonson, Star Tribune

 

According to the Institute of Medicine (IOM) report, an estimated figure of 44,000-98,000 patients die each year as a result of medical errors. Focusing on the medication error portion of the puzzle, it is estimated that approximately $2 billion is spent on treating hospitalized patients for preventable adverse drug events.Look- a-like drug names, (brand-brand, brand-generic, and generic-generic).  As of result of this issue, the new goal requires institutions to implement policies to identify look-alike drug names and implement strategies to prevent errors associated with these medication name mix-ups.

The JCAHO website is a valuable resource for look-alike and sound-alike drug names and includes information on preventing mix-ups for many problematic medications. These look-alike names cause errors in all aspects of the medication-use process: prescribing, transcribing, and dispensing of medications. There are many issues that contribute to an error associated with a look-alike name:

  • Poor handwriting-leads to misinterpretation of a written order.
  • Non-formulary medications-pharmacy and/or nursing staff may be unfamiliar with non-formulary medications and may mistake the order for a look-alike formulary medication.
  • Newly marketed medication-Healthcare providers may not be familiar with a new medication and can mistake it for a look-alike medication that has been in use for a longer period of time.

Table 1.  Examples of Look-Alike and Sound-Alike Medication Names*

Adriamycin – Idamycin

Celebrex – Celexa – Cerebra

Hydralazine – Hydroxyzine

Phenobarbital – Pentobarbital

Aggrenox – Aggrastat

Dopamine – Dobutamine

Imdur – Imuran

Quinidine – Quinine

Akarpine – Atropine

DiaBeta – Zebeta

Inderal – Isordil

Relafen – Rezulin

Alkeran – Leukeran

Diprivan – Diflucan

Klonopin – Clonidine

Retrovir – Ritonavir

Brevibloc – Brevital

Doxorubicin – Daunorubicin

Lamisil – Lamictal

Rifabutin – Rifampin

Bupivacaine – Ropivacaine

Efudex – Eurax

Lodine – Codeine

Seroquel – Serentil – Serzone

Bupropion – Buspirone

Eldepryl – Enalapril

Lopid – Slo-bid

Sulfasalazine – Sulfadiazine

Cafergot – Carafate

Equagesic – EquiGesic

Lorazepam – Clonazepam

Tobrex – TobraDex

Calcitriol – Calciferol

Etomidate – Etidronate

Mitomycin – Mitoxantrone

Vanceril – Vancenase

Carboplatin – Cisplatin

Folic acid – Folinic acid

Nelfinavir – Nevirapine

Vancomycin – Vecuronium  

Cardene – Cardizem

Glipizide – Glyburide

Nicardipine – Nifedipine – Nimodipine

 Vesicare – Visicol

Cardura – Coumadin

Guaifenesin – Guanfacine

Oxycodone – OxyContin

 Viramune – Viracept

Ceftazidime – Ceftizoxime

Humalog – Humulin

Paxil – Plavix

 Zosyn – Zofran

·         *For a more complete list of look-alike/sound-alike drug names visit: www.usp.org

While there is a mechanism now in place to address the process of assigning new drug names, the risk of medication errors from look-alike, sound-alike drugs still exists. One strategy aimed at minimizing prescribing errors associated with look-alike drug names is for the physician to include the medication’s indication on the prescription. This gives the pharmacist additional information to validate his/her interpretation of the prescription. For example, an order for hydroxyzine 50 mg PO q6h for itching is not likely to be misinterpreted as hydralazine. As discussed earlier, preprinted orders or physician order entry systems will prevent those look-alike medication errors where handwriting plays a role.

Sound-alike Drug Names
Verbal orders are a source of errors with sound-alike drug names. Oftentimes the actual transmittal of a verbal order is problem prone. Speech patterns (speaking too fast, too softly, with an accent, etc.) affect the ability of a pharmacist to accurately receive and transcribe the order. Further, the environment of the healthcare provider receiving the order can be filled with distracting noises (faxes, equipment alarms, co-worker conversations, etc.). Strengths and directions for use can also be misinterpreted when taking verbal orders (eg, 15 confused for 50). The entire process is filled with the potential for miscommunication and errors.

Ambulatory clinics and physicians’ offices will oftentimes “call in” prescriptions. This process usually starts with a written order (which is subject to all of the problems associated with written prescriptions) that is then phoned to a pharmacy. The nurse calling in the prescription may be unfamiliar with the drug name, doses, and indications. This can lead to mispronunciation of the drug name or misreading of dosing instructions to the pharmacy. The more steps and intermediaries (eg, nurse or clerk) introduced into the process, the more likely an error will occur. This is also true when a patient requests a transfer of a prescription from one pharmacy to another. The procedure of transmitting the prescription from pharmacy 1 to pharmacy 2 is yet another opportunity for introducing error into the process.

Safe practices would dictate:

  • Use verbal orders only for emergency situations when a written order is not possible.
  • Always read back a verbal order so that the prescriber can validate the order.
  • Obtain the indication for the prescribed drug; as with written prescriptions, this piece of information can serve to validate the drug choice.
  • Prohibit the use of verbal orders for certain high-risk medications, such as chemotherapy.
  • Establish policies on who can receive verbal orders.
  • Whenever possible, the prescriber should call in prescriptions to the pharmacy.
  • The pharmacist should ask to speak to the prescriber directly if there are any questions regarding a prescription that is being called in by office personnel.

HIGH-ALERT MEDICATIONS

Medications are deemed high alert not because they are more prone to errors than other medications but because of the serious harm that can result from administering the drug in error. As early as 1993, certain medications were tagged as “today’s poisons.” Some of those same medications still remain as high-alert medications (Table 3).JCAHO has made one high-alert medication a priority by including it in one of its patient safety goals. In order to improve the safety of high-alert medications, the goal states that concentrated electrolytes should be removed from patient care units and that institutions should standardize and limit the number of drug concentrations available.


Table 3.  High-Alert Medications

Adrenergic Agonists

Digoxin

Lidocaine

Theophylline

Heparin, thrombolytics and warfarin

*Intravenous magnesium

Benzodiazepines

*Hypertonic and hypotonic saline

Narcotic and opiates

*Intravenous calcium

Insulin

Neuromuscular blocking agents

Chemotherapeutic agents

Oral hypoglycemic agents

Cardioplegia

Chloral hydrate

*Potassium (Chloride or phosphate

Colchicine

*Included in JCAHO patient safety goal


Each high-alert medication has its own set of breakdown points and possible solutions. Some of the measures implemented to prevent problems with high-alert medications can include:

  • Limit availability of medication (remove from floor stock);
  • Utilize double checks; can occur at the dispensing or administering point of the medication-use process;
  • Utilize caution labels;
  • Review storage practices for those items that must remain available for use;
  • Standardize ordering procedures; use pre-printed orders when possible;
  • Use premixed solutions when possible;
  • Require double checks on calculations;
  • Use only pumps that are protected from free flow;
  • Implement maximum dosing alerts in pharmacy computer systems;
  • Develop standards for monitoring of some high-alert medications;
  • Prohibit bolus doses from infusion bags.

Retrieved from:

http://www.thecesolution.com/ce/lessons/PDQ_MedicationErrors_120105/MedicationErrors.htm