Presentation on theme: "Look-Alike and Sound-Alike Medications Practitioner Perspectives"— Presentation transcript:
1 Look-Alike and Sound-Alike Medications Practitioner Perspectives Timothy Lesar, Pharm.D.Director of PharmacyAlbany Medical CenterAlbany, NY
2 Practitioner perspectives Evidence base for commentsDrug product – medical care system interactions and risk for errorsSelect examplesImplications for risk reductionImplications for safety enhancements
3 Evidence base for comments Systematic error detection, assessment, categorization and recording at AMC (since 1987) (> 32,000 prescribing errors)Nature of errors and contributors identified> 20% related to drug names and nomenclatureLesar et al, JAMA 1990;263:Lesar, Ann Intern Med 1992;117:537-8Lesar et al, Arch Intern Med 1997;157:Lesar et al, JAMA 1997;27:312-7Lesar, Arch Pediatr Adolesc Med 1998;152:340-4Purdy et al, Ann Pharmacother 2000;833-8Lesar, J Gen Intern Med 2002;17:579-87Lesar, Ann Pharmacother 2002;36:1833-9
4 A GROWING PROBLEM:Number of dosage form related errors at AMC from 1996 to (> 75% related to nomenclature)
5 Emotional base for comments Drug names, nomenclature and packaging:Often have a clear potential for errorCommonly cause or contribute to patient harm.Cause or contribute to 2 or more significant medication errors every day at AMCPerception that safety is not always primary consideration in product naming.Simple product changes will reduce risk for error and enhance overall safety!
6 Conceptual FrameworkDrug 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 processesErrors occur in predictable ways!Allows risk assessmentAllows risk reductionAllows error prevention
7 Conceptual Framework Error producing conditions Risk for error and ADEError producing conditionsLikelihood of error occurringEnvironment and processes of careDrug(s) involvedPatient characteristic(s)Nature and type of error
8 Conceptual Framework Dose, strength(s), dose form, packaging Any or all characteristics of a drug product can increase or decrease risk, and MUST be considered in risk assessment:Generic name, brand nameDose, strength(s), dose form, packagingRoute, frequency, instructionsStorage requirementsIndications, patient populationLikely care environmentOther
9 Conceptual FrameworkDrug productERRORThe medical care “vortex”
10 ERRORS! Stress Culture New / Changed Product Or Process Suffixes ComputersMarketingComboproductSuffixesAbbreviationsBrand namesStressDosesLegibilityTeamNomenclatureDoseRegimensPatientLabelsCareSettingCare ProcessesCommunicationsNew /Changed ProductOrProcessFatigueDose formsRoutesCultureKnowledgeWorkconditionSymbolsIndicationLanguageTaskGeneric namesHuman factorsUBCStoragePackagingPurchasingERRORS!Preparation
11 Selected ExamplesMedication products in the medical care “vortex”
12 Predictable problems: Insulin brand names Humulin “Log” ordered instead of Humulin-L (Lente).Nurse thought Humalog” was to be given.
13 Names and labels: Novolog is “regular” (“R” )insulin, right?
15 Dosage form names: Just a matter of time…… 0.5mg, 1mg, 2mg, 3mg tabletsXR
16 Legibility and drug names Unasyn or Vancomycin?Protonix or Protamine?Capoten or Cozaar?
17 Technology-drug product interface: Levophed for Lopressor
18 Why dose, route, frequency and indication are important: Error detected because dose was differentTricor for TracleerProscar in a female??Error NOT detected because dose was the same
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 errorsRisk 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 apparentThe predictable nature of errors provides opportunity for product naming and design which reduces risk and enhances safety.