Look-Alike and Sound-AlikeMedications

Practitioner Perspectives

Timothy Lesar, Pharm.D.Timothy Lesar, Pharm.D.

Director of PharmacyDirector of Pharmacy

Albany Medical CenterAlbany Medical Center

Albany, NY Albany, NY

Practitioner perspectives

Evidence base for commentsEvidence base for comments Drug product – medical care system Drug product – medical care system

interactions and risk for errorsinteractions and risk for errors Select examplesSelect examples Implications for risk reductionImplications for risk reduction Implications for safety enhancementsImplications for safety enhancements

Evidence base for comments Systematic error detection, assessment, categorization Systematic error detection, assessment, categorization

and recording at AMC (since 1987) (> 32,000 and recording at AMC (since 1987) (> 32,000 prescribing errors) 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;263:2329-34Lesar et al, JAMA 1990;263:2329-34 Lesar, Ann Intern Med 1992;117:537-8Lesar, Ann Intern Med 1992;117:537-8 Lesar et al, Arch Intern Med 1997;157:1569-76Lesar et al, Arch Intern Med 1997;157:1569-76 Lesar et al, JAMA 1997;27:312-7Lesar et al, JAMA 1997;27:312-7 Lesar, Arch Pediatr Adolesc Med 1998;152:340-4 Lesar, Arch Pediatr Adolesc Med 1998;152:340-4 Purdy et al, Ann Pharmacother 2000;833-8Purdy et al, Ann Pharmacother 2000;833-8 Lesar, J Gen Intern Med 2002;17:579-87Lesar, J Gen Intern Med 2002;17:579-87 Lesar, Ann Pharmacother 2002;36:1833-9Lesar, Ann Pharmacother 2002;36:1833-9

0

50

100

150

200

250

300

350

1996 1997 1998 1999 2000

Err

ors

per

year

A GROWING PROBLEM:Number of dosage form related errors at AMC from

1996 to 2000 (> 75% related to nomenclature)

Emotional base for comments Drug names, nomenclature and packaging:Drug names, nomenclature and packaging:

Often have a clear potential for error Often have a clear potential for error Commonly cause or contribute to patient harm.Commonly cause or contribute to patient harm. Cause or contribute to Cause or contribute to 2 or more2 or more significant significant

medication errors medication errors every dayevery day at AMC at AMC PerceptionPerception that safety is not always primary that safety is not always primary

consideration in product naming. consideration in product naming. Simple product changes will reduce risk for error Simple product changes will reduce risk for error

and enhance overall safety!and enhance overall safety!

Conceptual Framework Drug product inserted into complex care environment.Drug product inserted into complex care environment. Drug product interacts with care environment and care Drug product interacts with care environment and care

processes in identifiable (often surprising) and predictable processes in identifiable (often surprising) and predictable fashion.fashion.

These interactions will be determined by specific product These interactions will be determined by specific product characteristics and specific care processes characteristics and specific care processes

Errors occur in predictable ways!Errors occur in predictable ways! Allows risk assessmentAllows risk assessment Allows risk reductionAllows risk reduction Allows error preventionAllows error prevention

Conceptual Framework Risk for error and ADERisk for error and ADE

Error producing conditionsError producing conditions Likelihood of error occurringLikelihood of error occurring Environment and processes of careEnvironment and processes of care Drug(s) involvedDrug(s) involved Patient characteristic(s)Patient characteristic(s) Nature and type of errorNature and type of error

Conceptual Framework Any or all characteristics of a drug product can increase Any or all characteristics of a drug product can increase

or decrease risk, and MUST be considered in risk or decrease risk, and MUST be considered in risk assessment:assessment: Generic name, brand nameGeneric name, brand name Dose, strength(s), dose form, packagingDose, strength(s), dose form, packaging Route, frequency, instructionsRoute, frequency, instructions Storage requirementsStorage requirements Indications, patient populationIndications, patient population Likely care environmentLikely care environment OtherOther

Conceptual Framework

The medical care “vortex”The medical care “vortex”

Drug productDrug product

ERRORERROR

Stress

Care Process

es

Brand names

Dose forms

Generic names

Doses

Routes

Communications

Labels

Symbols

Abbreviations

Legibility

Human

factorsStorage

UBC

Packaging

Computers

Culture

Marketing

Workconditio

n

Fatigue

Language

SuffixesCombo

product

Patient

Indication

CareSettin

g

Preparation

Purchasing

New /Changed Product

OrProcess

Task

Team

NomenclatureDose

Regimens

Knowledge

ERRORS!

Selected Examples

Medication products in the Medication products in the medical care “vortex”medical care “vortex”

Predictable problems:Insulin brand names

Humulin “Log” ordered instead of Humulin-L (Lente).

Nurse thought Humalog” was to be given.

Names and labels:Novolog is “regular” (“R” )insulin, right?

Dosage form names: OxyContin and MSContin

Dosage form names:Just a matter of time……

0.5mg, 1mg, 2mg, 3mg tablets

XR

Legibility and drug names

Capoten or Cozaar?

Protonix or Protamine?

Unasyn or Vancomycin?

Technology-drug product interface:Levophed for Lopressor

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??

Practitioner perspectives Implications for risk reduction and safety enhancements Predictable nature of errors allows risk assessment Predictable nature of errors allows risk assessment

and reduction. and reduction. Predictable nature of errors allows product design Predictable nature of errors allows product design

which can which can enhanceenhance safety. safety. All drug product characteristics must be All drug product characteristics must be

considered in risk assessment and prevention. considered in risk assessment and prevention. Care environment and processes must be Care environment and processes must be

considered in risk assessment and prevention.considered in risk assessment and prevention.

Practitioners perspective Summary

Drug names, labels and packaging are major Drug names, labels and packaging are major contributors to medication errorscontributors to medication errors

Risk for error is determined by both drug product Risk for error is determined by both drug product characteristics and the care system processes.characteristics and the care system processes.

Risk assessment must include multiple drug Risk assessment must include multiple drug characteristics (not just names)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 The predictable nature of errors provides opportunity

for product naming and design which reduces risk and for product naming and design which reduces risk and enhancesenhances safety. safety.