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Look-Alike and Sound-Alike Medications Practitioner Perspectives Timothy Lesar, Pharm.D. Director of Pharmacy Albany Medical Center Albany, NY.

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Presentation on theme: "Look-Alike and Sound-Alike Medications Practitioner Perspectives Timothy Lesar, Pharm.D. Director of Pharmacy Albany Medical Center Albany, NY."— Presentation transcript:

1 Look-Alike and Sound-Alike Medications Practitioner Perspectives Timothy Lesar, Pharm.D. Director of Pharmacy Albany Medical Center Albany, NY

2 Practitioner perspectives Evidence base for comments Evidence base for comments Drug product – medical care system interactions and risk for errors Drug product – medical care system interactions and risk for errors Select examples Select examples Implications for risk reduction Implications for risk reduction Implications for safety enhancements Implications for safety enhancements

3 Evidence base for comments Systematic error detection, assessment, categorization and recording at AMC (since 1987) (> 32,000 prescribing errors) Systematic error detection, assessment, categorization and recording at AMC (since 1987) (> 32,000 prescribing errors) Nature of errors and contributors identified Nature of errors and contributors identified > 20% related to drug names and nomenclature > 20% related to drug names and nomenclature  Lesar et al, JAMA 1990;263:  Lesar, Ann Intern Med 1992;117:537-8  Lesar et al, Arch Intern Med 1997;157:  Lesar et al, JAMA 1997;27:312-7  Lesar, Arch Pediatr Adolesc Med 1998;152:340-4  Purdy et al, Ann Pharmacother 2000;833-8  Lesar, J Gen Intern Med 2002;17:  Lesar, Ann Pharmacother 2002;36:1833-9

4 A GROWING PROBLEM: Number of dosage form related errors at AMC from 1996 to 2000 (> 75% related to nomenclature)

5 Emotional base for comments Drug names, nomenclature and packaging: 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 inserted into complex care environment. Drug product interacts with care environment and care processes in identifiable (often surprising) and predictable fashion. 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 These interactions will be determined by specific product characteristics and specific care processes Errors occur in predictable ways! Errors occur in predictable ways!  Allows risk assessment  Allows risk reduction  Allows error prevention

7 Conceptual Framework Risk for error and ADE 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: 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 The medical care “vortex” Drug product ERROR

10 Stress Care Process es Brand names Dose forms Generic names Dose s Routes Communication s Labels Symbol s Abbreviations Legibility Huma n factors Storage UBC Packagin g Computer s Cultur e Marketing Work conditio n Fatigu e Language Suffixes Comb o produc t Patient Indicatio n Care Settin g Preparatio n Purchasin g New / Changed Product Or Process Task Team Nomenclature Dose Regimen s Knowledge ERRORS !

11 Selected Examples Medication 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?

14 Dosage form names: OxyContin and MSContin

15 Dosage form names: Just a matter of time…… 0.5mg, 1mg, 2mg, 3mg tablets XR

16 Legibility and drug names Capoten or Cozaar? Protonix or Protamine? Unasyn or Vancomycin?

17 Technology-drug product interface: Levophed for Lopressor

18 Why dose, route, frequency and indication are important: Tricor for Tracleer Error detected because dose was different 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 risk assessment and reduction. Predictable nature of errors allows product design which can enhance safety. Predictable nature of errors allows product design which can enhance safety. All drug product characteristics must be considered in risk assessment and prevention. All drug product characteristics must be considered in risk assessment and prevention. Care environment and processes 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 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 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 assessment must include multiple drug characteristics (not just names) Risk of error within care system often readily apparent 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. The predictable nature of errors provides opportunity for product naming and design which reduces risk and enhances safety.


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