Look-Alike and Sound-Alike Medications Practitioner Perspectives

1
Look-Alike and Sound-AlikeMedicationsPractitione
r Perspectives

• Timothy Lesar, Pharm.D.
• Director of Pharmacy
• Albany Medical Center
• Albany, NY

2
Practitioner perspectives

• Evidence base for comments
• Drug product medical care system interactions
  and risk for errors
• Select examples
• Implications for risk reduction
• Implications for safety enhancements

3
Evidence base for comments

• Systematic error detection, assessment,
  categorization and recording at AMC (since 1987)
  (gt 32,000 prescribing errors)
• Nature of errors and contributors identified
• gt 20 related to drug names and nomenclature
• Lesar et al, JAMA 19902632329-34
• Lesar, Ann Intern Med 1992117537-8
• Lesar et al, Arch Intern Med 19971571569-76
• Lesar et al, JAMA 199727312-7
• Lesar, Arch Pediatr Adolesc Med 1998152340-4
• Purdy et al, Ann Pharmacother 2000833-8
• Lesar, J Gen Intern Med 200217579-87
• Lesar, Ann Pharmacother 2002361833-9

4
A GROWING PROBLEM Number of dosage form related
errors at AMC from 1996 to 2000 (gt 75 related
to nomenclature)
5
Emotional base for comments

• Drug names, nomenclature and packaging
• Often have a clear potential for error
• Commonly cause or contribute to patient harm.
• Cause or contribute to 2 or more significant
  medication errors every day at AMC
• Perception that safety is not always primary
  consideration in product naming.
• Simple product changes will reduce risk for error
  and enhance overall safety!

6
Conceptual Framework

• Drug product inserted into complex care
  environment.
• Drug product interacts with care environment and
  care processes in identifiable (often surprising)
  and predictable fashion.
• These interactions will be determined by specific
  product characteristics and specific care
  processes
• Errors occur in predictable ways!
• Allows risk assessment
• Allows risk reduction
• Allows error prevention

7
Conceptual Framework

• Risk for error and ADE
• Error producing conditions
• Likelihood of error occurring
• Environment and processes of care
• Drug(s) involved
• Patient characteristic(s)
• Nature and type of error

8
Conceptual Framework

• Any or all characteristics of a drug product can
  increase or decrease risk, and MUST be considered
  in risk assessment
• Generic name, brand name
• Dose, strength(s), dose form, packaging
• Route, frequency, instructions
• Storage requirements
• Indications, patient population
• Likely care environment
• Other

9
Conceptual Framework
Drug product
ERROR
The medical care vortex
10
Computers
Marketing
Suffixes
Combo product
Abbreviations
Brand names
Stress
Doses
Legibility
Team
Nomenclature
Labels
Patient
Dose Regimens
Care Setting
Care Processes
Communications
Fatigue
New / Changed Product Or Process
Dose forms
Routes
Culture
Knowledge
Symbols
Work condition
Indication
Language
Task
Generic names
Human factors
UBC
Storage
Packaging
ERRORS!
Purchasing
Preparation
11
Selected Examples
Medication products in the medical care vortex
12
Predictable problemsInsulin brand names
Humulin Log ordered instead of Humulin-L
(Lente). Nurse thought Humalog was to be given.
13
Names and labelsNovolog is regular (R
)insulin, right?
14
Dosage form names OxyContin and MSContin
15
Dosage form namesJust a matter of time
0.5mg, 1mg, 2mg, 3mg tablets
XR
16
Legibility and drug names
Unasyn or Vancomycin?
Protonix or Protamine?
Capoten or Cozaar?
17
Technology-drug product interfaceLevophed for
Lopressor
18
Why dose, route, frequency and indication are
important
Error detected because dose was different
Tricor for Tracleer
Error NOT detected because dose was the same
Proscar in a female??
19
Practitioner perspectives Implications for risk
reduction and safety enhancements

• Predictable nature of errors allows risk
  assessment and reduction.
• Predictable nature of errors allows product
  design which can enhance safety.
• All drug product characteristics must be
  considered in risk assessment and prevention.
• Care environment and processes must be considered
  in risk assessment and prevention.

20
Practitioners perspective Summary

• Drug names, labels and packaging are major
  contributors to medication errors
• Risk for error is determined by both drug product
  characteristics and the care system processes.
• Risk assessment must include multiple drug
  characteristics (not just names)
• Risk of error within care system often readily
  apparent
• The predictable nature of errors provides
  opportunity for product naming and design which
  reduces risk and enhances safety.