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Tsuji T, Nagata K, Tanaka M, Hasebe S, Yukita T, Uchida M, Suetsugu K, Hirota T, Ieiri I. Eye-tracking-based analysis of pharmacists' thought processes in the dispensing work: research related to the efficiency in dispensing based on right-brain thinking. J Pharm Health Care Sci 2024; 10:21. [PMID: 38730458 PMCID: PMC11084062 DOI: 10.1186/s40780-024-00341-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Pharmacists should be aware of their thought processes in dispensing work, including differences in the dispensing complexities owing to different drug positions in the left, center, and right areas. Dispensing errors associated with "same-name drugs (a pair of drugs with the same name but a different ingredient quantity)" are prevalent and often negatively affect patients. In this study, using five pairs of comparative models, the gaze movements of pharmacists in dispensing work were analyzed using an eye-tracking method to elucidate their thought processes. METHODS We prepared verification slides and displayed them on a prescription monitor and three drug rack monitors. The dispensing information (drug name, drug usage, location display, and total amount) was displayed on a prescription monitor. A total of 180 drugs including five target drugs were displayed on the three drug rack monitors. Total gaze points in the prescription area, those in the drug rack area, total vertical movements between the two areas, and time required to dispense drugs were measured as the four classifications Gaze 1, Gaze 2, Passage, and Time, respectively. First, we defined the two types of location displays as "numeral combination" and "color/symbol combination." Next, we defined two pairs of models A1-A2 (numerals) and B1-B2 (color/symbol) to compare differences between the left and right areas. Moreover, three pairs of models C1-C2 (left), D1-D2 (center), and E1-E2 (right) were established to compare differences between "numeral combination" and "color/symbol combination." RESULTS Significant differences in the complexities of dispensing work were observed in Gaze 2, Passage, and Time between the models A1-A2 (A1 B2), and in Gaze 2 and Time between the models C1-C2, D1-D2, and E1-E2 (C1>C2, D1>D2, and E1>E2, respectively). CONCLUSIONS Using the current dispensing rules, pharmacists are not good at dispensing drugs located in the right area. An effective measure for reducing the dispensing complexity is to introduce visual information in the prescription content; the utilization of the right brain facilitates reducing the complexity in the right dispensing area.
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Affiliation(s)
- Toshikazu Tsuji
- Department of Clinical Pharmacy, Setsunan University, Osaka, Japan.
| | - Kenichiro Nagata
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
| | - Masayuki Tanaka
- Department of Clinical Pharmacy, Setsunan University, Osaka, Japan
| | - Shigeru Hasebe
- Department of Clinical Pharmacy, Setsunan University, Osaka, Japan
| | - Takashi Yukita
- Department of Clinical Pharmacy, Setsunan University, Osaka, Japan
| | - Mayako Uchida
- Department of Education and Research Center for Pharmacy Practice, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyoto, Japan
| | | | - Takeshi Hirota
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
| | - Ichiro Ieiri
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
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Sardana K, Rose Mathachan S. Iatrogenic irritant contact dermatitis to podophyllin and the perils of look-alike, sound-alike trade names in dermatology. Indian J Dermatol Venereol Leprol 2024; 90:110-112. [PMID: 37317734 DOI: 10.25259/ijdvl_72_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/31/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Kabir Sardana
- Department of Dermatology, ABVIMS & Dr RML Hospital, Connaught Place, New Delhi, Delhi, India
| | - Sinu Rose Mathachan
- Department of Dermatology, ABVIMS & Dr RML Hospital, Connaught Place, New Delhi, Delhi, India
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3
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Jayasinghe M, Srilal TLI, Subasinghe S, Zawahir S. Identification of Confusing Medicine Proprietary Names: Toward Safe Medicine Use-A Cross-Sectional Study in Sri Lanka. Ther Innov Regul Sci 2023; 57:1248-1259. [PMID: 37592154 DOI: 10.1007/s43441-023-00557-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Look-alike sound-alike (LASA) medications have similar pronunciation (phonetic) and/or manifestation (orthographic), which could create confusion among users and challenge the safe use of medicines. The availability of foreign products in local markets aggravates the situation. This study was designed to examine the registered medicine proprietary names in Sri Lanka to discern the presence of similar medicine names in the industry. METHODS A cross-sectional study was conducted on the registered drug proprietary names in Sri Lanka. Using the RAND and RANK functions in Microsoft® excel® 365, a random sample of 385 proprietary names was selected. Two evaluators independently evaluated each proprietary name in the sample against the other registered proprietary names following a stepwise text filtering method. After each filter, the resulting proprietary names were manually examined for identical, similar-looking, and similar-sounding proprietary names to the name under evaluation. The observations were matched, categorized, and collated into ten groups. RESULTS Among the 385 names evaluated, 138 (35.84%) proprietary names had no similarity to existing other registered proprietary names. The rest of the names (n = 247, 64.15%) were found to be either identical (n = 03 pairs), look-alike (n = 91 pairs), or sound-alike (n = 80 pairs) to the registered proprietary names. CONCLUSION The findings revealed the presence of equal and similar proprietary names in the system. A multifactorial strategy led by the National Medicine Regulatory Authority (NMRA) is recommended to minimize the confusing names entering the system. Primarily the NMRA's call for action should include adequate industry guidance with specific guidelines, a significant pre-submission assessment process, and denying approval of LASA proprietary names.
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Affiliation(s)
- Manori Jayasinghe
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Ruhuna, Karapitiya, Galle, 80000, Sri Lanka.
| | | | - Sewwandi Subasinghe
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Ruhuna, Karapitiya, Galle, 80000, Sri Lanka
| | - Shukry Zawahir
- Sydney School of Medicine (Central Clinical School), Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
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Karet GB. Linguistic Analysis of Generic-Generic Drug Name Pairs Prone to Wrong-Drug Errors for which Tall-Man Lettering is Recommended. Ther Innov Regul Sci 2023; 57:751-758. [PMID: 37171707 PMCID: PMC10276790 DOI: 10.1007/s43441-023-00526-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/14/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE The Institute for Safe Medication Practices (ISMP) and the United States Food and Drug Administration (FDA) disseminated widely used lists of drug name pairs involved in wrong-drug errors, for which they recommended tall-man lettering (TML). Linguistic similarity is believed responsible for confusion of these drugs. This study aims to quantify linguistic similarity and other linguistic properties of these generic-generic name pairs. METHODS The FDA's Phonetic and Orthographic Computer Analysis (POCA) software was used to generate numerical similarity scores for the generic-generic name pairs on these lists and to identify conflicts between these names and the names of other marketed products. Within each pair, differences in name length and the number of identical prefix (initial) letters and suffix (final) letters were determined. RESULTS The selected pairs shared a mean of 2.5 (± 1.8) identical prefix letters and 3.2 (± 2.9) identical suffix letters. The mean POCA score 69.5 (± 9.7), indicated moderate-to-high similarity. POCA scores for individual pairs ranged from 90 (most similar) to 46 (least similar). Individual names averaged 11.2 (± 9.1) high-similarity conflicts with names of other marketed drugs. CONCLUSIONS POCA analysis could be a valuable tool in determining whether linguistic similarity contributes to specific wrong-drug errors. The finding of 11.2 (± 9.1) high-similarity conflicts with names of other marketed drugs is more than for candidate names USAN accepts and suggests the names on the FDA and ISMP lists are linguistically problematic.
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Affiliation(s)
- Gail B Karet
- Senior Scientist, American Medical Association, United States Adopted Names Program, Suite 39300, 330 N. Wabash Ave, Chicago, IL, 60611-5885, USA.
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5
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Tsuji T, Nagata K, Sasaki K, Matsukane R, Ishida S, Kawashiri T, Suetsugu K, Watanabe H, Hirota T, Ieiri I. Analysis of the thinking process of pharmacists in response to changes in the dispensing environment using the eye-tracking method. J Pharm Health Care Sci 2022; 8:23. [PMID: 36045385 PMCID: PMC9434836 DOI: 10.1186/s40780-022-00254-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/26/2022] [Indexed: 08/23/2023] Open
Abstract
Background Pharmacists must understand the mechanisms by which dispensing errors occur and take appropriate preventive measures. In this study, the gaze movements of pharmacists were analyzed using an eye-tracking method, to elucidate the thinking process of pharmacists when identifying target drugs and avoiding dispensing errors. Methods We prepared verification slides and projected them on a large screen. Each slide comprised a drug rack area and a prescription area; the former consisted of a grid-like layout with 55 drugs and the latter displayed dispensing information (drug name, drug usage, location number, and total amount). Twelve pharmacists participated in the study, and three single-type drugs and six double-type drugs were used as target drugs. We analyzed the pharmacists’ method of identifying the target drugs, the mechanisms by which errors occurred, and the usefulness of drug photographs using the error-induction (−) /photo (+), error-induction (+) / (+), and error-induction (+) /photo (−) models. Results Visual invasion by non-target drugs was found to have an effect on the subsequent occurrence of dispensing errors. In addition, when using error-induction models, the rate of dispensing error was 2.8 and 11.1% for the photo (+) and photo (−) models, respectively. Furthermore, based on the analysis of eight pharmacists who dispensed drugs without errors, it was clear that additional confirmation of “drug name” was required to accurately identify the target drug in the photo (+) model; additionally, that of “location number” was required to pinpoint directly the position of target drug in the photo (−) model. Conclusions By analyzing the gaze movements of pharmacists using the eye-tracking method, we clarified pharmacists’ thinking process which was required to avoid dispensing errors in a complicated environment and proved the usefulness of drug photographs in terms of both reducing the complexity of the dispensing process and the risk of dispensing errors. Effective measures to prevent dispensing errors include ensuring non-adjacent placement of double-type drugs and utilization of their image information.
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Affiliation(s)
- Toshikazu Tsuji
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan.
| | - Kenichiro Nagata
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
| | - Keiichi Sasaki
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
| | | | - Shigeru Ishida
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
| | - Takehiro Kawashiri
- Clinical Pharmacy Education Center, Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | | | | | - Takeshi Hirota
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
| | - Ichiro Ieiri
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
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Millán-Hernández CE, García-Hernández RA, Ledeneva Y. Improving the identification of confused drug names in Spanish. JOURNAL OF INTELLIGENT & FUZZY SYSTEMS 2020. [DOI: 10.3233/jifs-179869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Since a drug name goes through different communication means and circumstances when it is prescribed, written, advertised, listened to, searched and administered; it tends to be confused with similar drug names that Look-Alike and Sound-Alike (LASA). LASA drug names have caused costs and damage to health. For this problem, the institutions of the United Kingdom, Canada, and the United States have implemented programs for several decades to report lists of confusing drug names pairs. Thanks to these kinds of list, it has been possible to propose new models to identify confusing drug names in English and are used to reject new drug name proposals or to alert when a confusing drug name is being dispensed. However, countries such as Spain also have published a list with the Spanish LASA drug names, and it is not clear enough whether the models previously proposed for the drug names in English are useful for the list in Spanish or if it is necessary to adjust and update them for the Spanish language. This paper focuses on updating and improving the identification of LASA drug names in Spanish. First, we update the state-of-the-art by evaluating all the individual similarity measures proposed previously and all the models that combine these measures with the list in Spanish. Second, we updated the models with new individual measures and then adjusted them with the list in Spanish to improve the identification of LASA drug names in Spanish. After that, 25 individual similarity measures and 8 models to identify confused drug names in Spanish are compared to obtain the best result and conclusions.
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Affiliation(s)
| | | | - Yulia Ledeneva
- Autonomous University of State of Mexico, Instituto Literario, Centro, Toluca, Mexico
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Vázquez EV, Ledeneva Y, García-Hernández RA. Combination of similarity measures based on symbolic regression for confusing drug names identification. JOURNAL OF INTELLIGENT & FUZZY SYSTEMS 2020. [DOI: 10.3233/jifs-179875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite advances in medical safety, errors related to adverse drug reactions are still very common. The most common reason for a patient to develop an adverse reaction to a medication is confusion over the prescribed medication. The similarity of drug names (by their spelling or phonetic similarity) is recognized as the most critical factor causing medication confusion. Several studies have studied techniques for the identification of confusing medications pairs, the most important of which employ techniques based on similarity measures that indicate the degree of similarity that exists between two drugs names. Although it generates good results in the identification of confusing drug names, each of the similarity measures used detects to a greater or lesser degree of similarity that exists between a pair. Recent studies indicate that the optimized combination of several similarity measures can generate better results than the individual application of each one. This paper presents an optimized method of combining various similarity measures based on symbolic regression. The obtained results show an improvement in the identification of confusing drug names.
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Affiliation(s)
- Eder Vázquez Vázquez
- Autonomous University of the State of Mexico, Instituto Literario, Toluca, State of Mexico, Mexico
| | - Yulia Ledeneva
- Autonomous University of the State of Mexico, Instituto Literario, Toluca, State of Mexico, Mexico
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8
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Millán-Hernández CE, García-Hernández RA, Ledeneva Y, Hernández-Castañeda Á. An orthographic and phonetic knowledge-based measure for confused drug names. JOURNAL OF INTELLIGENT & FUZZY SYSTEMS 2020. [DOI: 10.3233/jifs-179867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A drug name could be confused because it looks or sounds like another. Nevertheless, it is not possible to know a priori the causes of the confusion. Nowadays, sophisticated similarity measures have been proposed focused on improving the score of the detection. However, when a new drug name is proposed, the Federal Drug Administration (FDA) only can reject or accept the drug name based on this value. This paper not only improves the detection of confused drug names by integrating the strengths of different similarity measures but also the orthographic and phonetic knowledge of these measures are used to give an a priori explanation of the causes of confusion. In this paper, a novel measure that integrates 24 individual measures is developed for this problem. With our proposal, each individual measure contributes to this problem. Finally, we present examples of how our proposal is used for explaining the causes of the confusion which could assist to the FDA to accept or reject a new drug name or to know the confusion causes of previously reported cases.
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Affiliation(s)
| | | | - Yulia Ledeneva
- Autonomous University of State of Mexico, Instituto Literario, Centro, Toluca, Mexico
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9
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Bryan R, Aronson JK, Williams A, Jordan S. The problem of look-alike, sound-alike name errors: Drivers and solutions. Br J Clin Pharmacol 2020; 87:386-394. [PMID: 32198938 DOI: 10.1111/bcp.14285] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/24/2020] [Accepted: 02/05/2020] [Indexed: 11/27/2022] Open
Abstract
Look-alike or sound-alike (LASA) medication names may be mistaken for each other, e.g. mercaptamine and mercaptopurine. If an error of this sort is not intercepted, it can reach the patient and may result in harm. LASA errors occur because of shared linguistic properties between names (phonetic or orthographic), and potential for error is compounded by similar packaging, tablet appearance, tablet strength, route of administration or therapeutic indication. Estimates of prevalence range from 0.00003 to 0.0022% of all prescriptions, 7% of near misses, and between 6.2 and 14.7% of all medication error events. Solutions to LASA errors can target people or systems, and include reducing interruptions or distractions during medication administration, typographic tweaks, such as selective capitalization (Tall Man letters) or boldface, barcoding, and computerized physician order entry.
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10
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Cassius C, Davis C, Bravard P, Carre‐Gislard D, Modiano P, Lebrun‐Vignes B, Ingen‐Housz‐Oro S, Chosidow O. Lookalike and soundalike drugs: a potential cause of cutaneous adverse reactions to drugs. Br J Dermatol 2019; 181:626-627. [DOI: 10.1111/bjd.17842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C. Cassius
- Department of Dermatology AP‐HP, Hôpital Henri‐Mondor Créteil France
| | - C.J. Davis
- School of Psychological Science University of Bristol Bristol U.K
| | - P. Bravard
- Department of Dermatology Hôpital Jacques Monod Le Havre France
| | | | - P. Modiano
- Department of Dermatology Hôpital Saint‐Vincent‐de‐Paul Lille France
| | - B. Lebrun‐Vignes
- Regional Center of Pharmacovigilance AP‐HP, Hôpitaux Universitaires Pitié‐Salpêtrière Paris France
- EpiDermE – EA 7379, Université Paris‐Est Créteil Créteil France
- Reference Center for Toxic Bullous Diseases and Severe Cutaneous Adverse Reactions Créteil France
- French Investigators for Skin Adverse Reactions to Drugs group (FISARD) of the French Society of Dermatology
| | - S. Ingen‐Housz‐Oro
- Department of Dermatology AP‐HP, Hôpital Henri‐Mondor Créteil France
- EpiDermE – EA 7379, Université Paris‐Est Créteil Créteil France
- Reference Center for Toxic Bullous Diseases and Severe Cutaneous Adverse Reactions Créteil France
- French Investigators for Skin Adverse Reactions to Drugs group (FISARD) of the French Society of Dermatology
| | - O. Chosidow
- Department of Dermatology AP‐HP, Hôpital Henri‐Mondor Créteil France
- EpiDermE – EA 7379, Université Paris‐Est Créteil Créteil France
- Reference Center for Toxic Bullous Diseases and Severe Cutaneous Adverse Reactions Créteil France
- Inserm, Centre d'Investigation Clinique 1430 Créteil France
- Université Paris‐Est Créteil Créteil France
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Lambert BL, Galanter W, Liu KL, Falck S, Schiff G, Rash-Foanio C, Schmidt K, Shrestha N, Vaida AJ, Gaunt MJ. Automated detection of wrong-drug prescribing errors. BMJ Qual Saf 2019; 28:908-915. [PMID: 31391313 PMCID: PMC6837246 DOI: 10.1136/bmjqs-2019-009420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 07/17/2019] [Accepted: 07/22/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND To assess the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data. SETTING Urban, academic medical centre, comprising a 495-bed hospital and outpatient clinic running on the Cerner EHR. We extracted 8 years of medication orders and diagnostic claims. We licensed a database of medication indications, refined it and merged it with the medication data. We developed an algorithm that triggered for LASA errors based on name similarity, the frequency with which a patient received a medication and whether the medication was justified by a diagnostic claim. We stratified triggers by similarity. Two clinicians reviewed a sample of charts for the presence of a true error, with disagreements resolved by a third reviewer. We computed specificity, positive predictive value (PPV) and yield. RESULTS The algorithm analysed 488 481 orders and generated 2404 triggers (0.5% rate). Clinicians reviewed 506 cases and confirmed the presence of 61 errors, for an overall PPV of 12.1% (95% CI 10.7% to 13.5%). It was not possible to measure sensitivity or the false-negative rate. The specificity of the algorithm varied as a function of name similarity and whether the intended and dispensed drugs shared the same route of administration. CONCLUSION Automated detection of LASA medication errors is feasible and can reveal errors not currently detected by other means. Real-time error detection is not possible with the current system, the main barrier being the real-time availability of accurate diagnostic information. Further development should replicate this analysis in other health systems and on a larger set of medications and should decrease clinician time spent reviewing false-positive triggers by increasing specificity.
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Affiliation(s)
- Bruce L Lambert
- Department of Communication Studies and Center for Communication and Health, Northwestern University, Chicago, Illinois, USA
| | - William Galanter
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA.,Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | - Suzanne Falck
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gordon Schiff
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Rash-Foanio
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kelly Schmidt
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Neeha Shrestha
- Department of Communication Studies and Center for Communication and Health, Northwestern University, Chicago, Illinois, USA
| | - Allen J Vaida
- Institute for Safe Medication Practices, Horsham, Pennsylvania, USA
| | - Michael J Gaunt
- Institute for Safe Medication Practices, Horsham, Pennsylvania, USA
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12
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Millán-Hernández CE, García-Hernández RA, Ledeneva Y. An evolutionary logistic regression method to identify confused drug names. JOURNAL OF INTELLIGENT & FUZZY SYSTEMS 2019. [DOI: 10.3233/jifs-179012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Yulia Ledeneva
- Autonomous University of the State of Mexico, Instituto Literario, col. Centro, Toluca, Mexico
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13
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Her QL, Toh S. Sound-Alike Look-Alike Confusion and Matching Medication Product Attributes: Simulated Case-Control Studies. Ann Pharmacother 2019; 53:973-980. [PMID: 30999762 DOI: 10.1177/1060028019838239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Sound-alike look-alike (SALA) medication confusions harm as many as 250 000 Americans annually. Most preventive strategies focus on medication name similarities. Objectives: To evaluate the association between matching medication product attributes and SALA confusion. Methods: We simulated 20 000 case-control studies using the Institute for Safe Medication Practices' List of Confused Drug Names as case pairs and 4 randomly selected control pairs per case pair from the First DataBank MedKnowledge (FDBM) database. We extracted 7 product attributes for each medication from the FDBM database. We used logistic regression models to estimate the associations between matching product attributes and SALA confusion. The models included a series of univariate (unadjusted) models, a model that adjusted for all product attributes, and a model that further adjusted for medication name similarity measures. Results: Medications with a matching product attribute had increased odds of SALA confusion in the univariate analyses (odds ratio [OR] = 4.2 to 55.5). When we simultaneously adjusted for all attributes, the associations of matching package unit, package unit size, formulation, strength, therapeutic class, and manufacturer with SALA confusion were attenuated but remained elevated (OR = 1.5 to 26.5), whereas the direction of association between matching route and SALA confusion reversed (OR = 0.8). These associations persisted on adjustment for medication name similarity measures. Conclusions and Relevance: This study is the first to evaluate the association between matching medication product attributes and SALA confusion with a control group. Having matching product attributes increased the odds of SALA confusion. SALA risk reduction strategies should consider product attributes.
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Affiliation(s)
- Qoua L Her
- 1 Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Sengwee Toh
- 1 Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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14
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Tetteh EK. Reducing avoidable medication-related harm: What will it take? Res Social Adm Pharm 2019; 15:827-840. [PMID: 30981449 DOI: 10.1016/j.sapharm.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 10/27/2022]
Abstract
Consumption of quality-assured medicines is expected to maintain or improve population health. Yet in a number of situations, what is realized is lower health benefits or magnified safety risks. Recognizing the public health implications of safety risks or medication-related harm, and that some types of harm are avoidable, the World Health Organization has initiated the third Global Patient Safety challenge on Medication Safety. Under the term "Medication Without Harm", this Challenge aims to assess the scope and nature of avoidable medication-related harm, create a framework for intervention and develop national guidance and tools to support safer medication use. The global target under the Challenge is to reduce the level of severe avoidable medication-related harm by 50% over a five-year period or within the next five years. Given a higher morbidity and mortality due to medication-related harm in low-income countries, this paper evaluates what needs to be done in low-income countries in order to achieve the global target. The ideal solution advocated requires that health planners in each low-income country determine what fraction of safety risks or harm can be prevented; and the relationship between number or frequency of avoidable harm or safety risks and the resource costs of treatment or prevention. In the absence of such information, this paper discusses a number of prevention strategies that might help; arguing that the period over which avoidable medication-related harm can be reduced by 50% will depend on whether significant continuous investments in health-system strengthening are made prior to and within that period.
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Affiliation(s)
- Ebenezer Kwabena Tetteh
- Department of Pharmacy Practice & Clinical Pharmacy, School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Accra, Ghana.
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15
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Abolhassani N, Akbari Sari A, Rashidian A, Rastegarpanah M. The establishment of the Drug Naming Committee to restrict look-alike medication names in Iran: A qualitative study. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2018; 29:69-79. [PMID: 28885221 DOI: 10.3233/jrs-170740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medication errors is a prominent issue on the health policy agenda due to its significant human and financial costs; confusing drug names are one of the most common causes of them. This issue necessitates the adoption of a mechanism to restrict such a confusion before approving drug names. OBJECTIVE Following the establishment of a committee and developed relevant criteria as mechanisms to address the issue of drug names similarity Iran, there were problems in this process. This study explores the process of adopting this mechanism. METHODS This qualitative study was conducted using date gathered through documents, observation and 31 semi-structured interviews. Ethical approval was achieved from the Research Ethics Committee in TUMS. Confidentiality was ensured at all the interviews. The interviews were recorded verbatim, transcribed and coded, using the MAXQDA ver.12 software. Data were analyzed utilizing the Health Policy Triangle Framework. RESULTS High rate of medication errors and warning from the WHO about drug names in Iran pushed the issue of drug proprietary names to the FDO agenda. A National Drugs Naming Committee was established and relevant criteria were developed by the Food and Drug Organization (FDO). This committee was dissolved for four years; the function was delegated to the General Office of Trademarks Registry. However, the committee was reestablished and resumed functioning. Finings mainly indicated a higher rate of medication errors during dissolving the committee. CONCLUSION Health policy-makers have a public responsibility for making a decision and the consequences. Regarding the process of naming drugs, it is important for policy makers to consider two issues: patient safety and trademarks rights. However, the Iran FDO adopted an approach to address these issues, a more multifaceted, integrated approach to initial naming of drugs is suggested. The committee' function is seen to hold the most promise. However the function is partially complete to ensure patient safety. Given the change experienced by altering relevant organizational authorities in the FDO, the sustainability of the committee cannot hope to be guaranteed. Yet, the need for such a guarantee is particularly important.
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Affiliation(s)
- Nazanin Abolhassani
- School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Akbari Sari
- School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Health Sciences, University of York, York, UK
| | - Arash Rashidian
- Department of Health Sciences, University of York, York, UK.,Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mansoor Rastegarpanah
- Department of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA.,Department of Clinical Pharmacy, College of Pharmacy, University of Medical Sciences, Tehran, Iran
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16
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Lesselroth BJ, Adams K, Church VL, Tallett S, Russ Y, Wiedrick J, Forsberg C, Dorr DA. Evaluation of Multimedia Medication Reconciliation Software: A Randomized Controlled, Single-Blind Trial to Measure Diagnostic Accuracy for Discrepancy Detection. Appl Clin Inform 2018; 9:285-301. [PMID: 29719884 DOI: 10.1055/s-0038-1645889] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The Veterans Affairs Portland Healthcare System developed a medication history collection software that displays prescription names and medication images. OBJECTIVE This article measures the frequency of medication discrepancy reporting using the medication history collection software and compares with the frequency of reporting using a paper-based process. This article also determines the accuracy of each method by comparing both strategies to a best possible medication history. STUDY DESIGN Randomized, controlled, single-blind trial. SETTING Three community-based primary care clinics associated with the Veterans Affairs Portland Healthcare System: a 300-bed teaching facility and ambulatory care network serving Veteran soldiers in the Pacific Northwest United States. PARTICIPANTS Of 212 patients with primary care appointments, 209 patients fulfilled the study requirements. INTERVENTION Patients randomized to a software-directed medication history or a paper-based medication history. Randomization and allocation to treatment groups were performed using a computer-based random number generator. Assignments were placed in a sealed envelope and opened after participant consent. The research coordinator did not know or have access to the treatment assignment until the time of presentation. MAIN OUTCOME MEASURES The primary analysis compared the discrepancy detection rates between groups with respect to the health record and a best possible medication history. RESULTS Of 3,500 medications reviewed, we detected 1,435 discrepancies. Forty-six percent of those discrepancies were potentially high risk for causing an adverse drug event. There was no difference in detection rates between treatment arms. Software sensitivity was 83% and specificity was 91%; paper sensitivity was 81% and specificity was 94%. No participants were lost to follow-up. CONCLUSION The medication history collection software is an efficient and scalable method for gathering a medication history and detecting high-risk discrepancies. Although it included medication images, the technology did not improve accuracy over a paper list when compared with a best possible medication history. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02135731.
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Affiliation(s)
- Blake J Lesselroth
- NorthWest Innovation Center, Veterans' Affairs Portland Healthcare System, Portland, Oregon, United States.,Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Kathleen Adams
- NorthWest Innovation Center, Veterans' Affairs Portland Healthcare System, Portland, Oregon, United States
| | - Victoria L Church
- NorthWest Innovation Center, Veterans' Affairs Portland Healthcare System, Portland, Oregon, United States
| | - Stephanie Tallett
- NorthWest Innovation Center, Veterans' Affairs Portland Healthcare System, Portland, Oregon, United States
| | - Yelizaveta Russ
- Division of Primary Care, Veterans' Affairs Portland Healthcare System, Portland, Oregon, United States
| | - Jack Wiedrick
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, Oregon, United States
| | - Christopher Forsberg
- Center of Innovation, Veterans' Affairs Portland Healthcare System, Portland, Oregon, United States
| | - David A Dorr
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
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17
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Pires C, Vigário M, Cavaco A. Brand names of Portuguese medication: understanding the importance of their linguistic structure and regulatory issues. CIENCIA & SAUDE COLETIVA 2017. [PMID: 26221822 DOI: 10.1590/1413-81232015208.13962014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Among other regulatory requirements, medicine brands should be composed of single names without abbreviations to prevent errors in prescription of medication. The purposes of the study were to investigate the compliance of a sam ple of Portuguese medicine brand names with Portuguese pharmaceutical regulations. This includes identifying their basic linguistic characteristics and comparing these features and their frequency of occurrence with benchmark values of the colloquial or informal language. A sample of 474 brand names was selected. Names were analyzed using manual (visual analyses) and computer methods (FreP - Frequency Patterns of Phonological Objects in Portuguese and MS word). A significant number of names (61.3%) failed to comply with the Portuguese phonologic system (related to the sound of words) and/or the spelling system (related to the written form of words) contained more than one word, comprised a high proportion of infrequent syllable types or stress patterns and included abbreviations. The results suggest that some of the brand names of Portuguese medication should be reevaluated, and that regulation on this issue should be enforced and updated, taking into consideration specific linguistic and spelling codes.
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Affiliation(s)
- Carla Pires
- Departamento de Sócio-Farmácia, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal,
| | - Marina Vigário
- Departamento de Linguística Geral, Faculdade de Letras, Universidade de Lisboa, Portugal
| | - Afonso Cavaco
- Departamento de Sócio-Farmácia, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal,
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18
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Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, Schiff G. Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. Expert Opin Drug Saf 2017; 16:1103-1109. [DOI: 10.1080/14740338.2017.1358361] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Enrique Seoane-Vazquez
- Department of Biomedical and Pharmaceutical Sciences, Chapman University School of Pharmacy, Irvine, CA, USA
| | - Rosa Rodriguez-Monguio
- Health Policy and Management, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Saad Alqahtani
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
| | - Gordon Schiff
- Division of General Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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19
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Degnan DD, Hertig JB, Peters MJ, Stevenson JG. Board of Pharmacy Practices Related to Medication Errors and Their Potential Impact on Patient Safety. J Pharm Pract 2017. [PMID: 28629304 DOI: 10.1177/0897190017715562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
State boards of pharmacy are generally responsible for the governance of the practice of pharmacy. While the regulatory process and methods for accomplishing this task may vary by state, all boards of pharmacy must address medication errors committed by pharmacists. The National Association of Boards of Pharmacy (NABP) has recommended that state boards of pharmacy implement best practices and enforcement actions that are aimed to promote patient safety and reduce medication errors. The current study was designed to identify and compare current corrective action practices among boards of pharmacy in response to medication errors. An electronic survey regarding board policies and anticipated board actions in response to hypothetical medication error scenarios was sent to boards of pharmacy for completion. Approximately 45% of pharmacy boards responded. Survey responses demonstrated that corrective actions and consequences were levied against pharmacists inconsistently among state boards. Corrective action plans and process improvement components were lacking in a majority of state board of pharmacy practices. Medication safety education for pharmacists and for members on boards of pharmacy was insufficient in many states. Responses to hypothetical error scenarios indicated that most board actions are educational and punitive in nature, rather than focusing on systems improvement.
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Affiliation(s)
- Daniel D. Degnan
- Center for Medication Safety Advancement, Purdue University College of Pharmacy, West Lafayette, IN, USA
| | - John B. Hertig
- Center for Medication Safety Advancement, Purdue University College of Pharmacy, West Lafayette, IN, USA
| | - Michael J. Peters
- Center for Medication Safety Advancement, Purdue University College of Pharmacy, West Lafayette, IN, USA
| | - James G. Stevenson
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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20
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Shah MB, Merchant L, Chan IZ, Taylor K. Characteristics That May Help in the Identification of Potentially Confusing Proprietary Drug Names. Ther Innov Regul Sci 2017; 51:232-236. [PMID: 30231718 PMCID: PMC7238771 DOI: 10.1177/2168479016667161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 07/07/2016] [Indexed: 11/15/2022]
Abstract
PURPOSE This study aimed to provide a descriptive analysis of characteristics that are common among drug name pairs involved in name confusion medication errors. METHODS We evaluated drug name pairs that contained at least one proprietary name from the Institute for Safe Medication Practices (ISMP) List of Confused Drug Names. For each name pair, we analyzed whether the following characteristics were present: (1) the same first letter, (2) a shared letter string of at least 3 letters, and (3) similarity in the number of letters. Additionally, we obtained the combined Phonetic and Orthographic Computer Analysis (POCA) score. RESULTS Ninety-nine percent of the drug name pairs reflected at least one of the 3 characteristics analyzed. Additionally, 75% of the names had a combined POCA score of ≥50%. CONCLUSIONS This descriptive analysis provides some insight into characteristics that may be associated with name confusion, which should be considered when formulating and evaluating proposed proprietary drug names.
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Affiliation(s)
- Millie B. Shah
- Food and Drug Administration, Center for Drug Evaluation and Research/Office of Surveillance and Epidemiology/Office of Medication Error Prevention and Risk Management/Division of Medication Error Prevention and Analysis, Silver Spring, MD, USA
| | - Lubna Merchant
- Food and Drug Administration, Center for Drug Evaluation and Research/Office of Surveillance and Epidemiology/Office of Medication Error Prevention and Risk Management/Division of Medication Error Prevention and Analysis, Silver Spring, MD, USA
| | - Irene Z. Chan
- Food and Drug Administration, Center for Drug Evaluation and Research/Office of Surveillance and Epidemiology/Office of Medication Error Prevention and Risk Management/Division of Medication Error Prevention and Analysis, Silver Spring, MD, USA
| | - Kellie Taylor
- Food and Drug Administration, Center for Drug Evaluation and Research/Office of Surveillance and Epidemiology/Office of Medication Error Prevention and Risk Management/Division of Medication Error Prevention and Analysis, Silver Spring, MD, USA
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21
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Hettinger AZ, Roth EM, Bisantz AM. Cognitive engineering and health informatics: Applications and intersections. J Biomed Inform 2017; 67:21-33. [PMID: 28126605 DOI: 10.1016/j.jbi.2017.01.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/13/2017] [Accepted: 01/17/2017] [Indexed: 10/20/2022]
Abstract
Cognitive engineering is an applied field with roots in both cognitive science and engineering that has been used to support design of information displays, decision support, human-automation interaction, and training in numerous high risk domains ranging from nuclear power plant control to transportation and defense systems. Cognitive engineering provides a set of structured, analytic methods for data collection and analysis that intersect with and complement methods of Cognitive Informatics. These methods support discovery of aspects of the work that make performance challenging, as well as the knowledge, skills, and strategies that experts use to meet those challenges. Importantly, cognitive engineering methods provide novel representations that highlight the inherent complexities of the work domain and traceable links between the results of cognitive analyses and actionable design requirements. This article provides an overview of relevant cognitive engineering methods, and illustrates how they have been applied to the design of health information technology (HIT) systems. Additionally, although cognitive engineering methods have been applied in the design of user-centered informatics systems, methods drawn from informatics are not typically incorporated into a cognitive engineering analysis. This article presents a discussion regarding ways in which data-rich methods can inform cognitive engineering.
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Affiliation(s)
- A Zachary Hettinger
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC, United States; National Center for Human Factors in Healthcare, MedStar Health, Washington, DC, United States.
| | - Emilie M Roth
- Roth Cognitive Engineering, Stanford, CA, United States
| | - Ann M Bisantz
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York, Buffalo, NY, United States
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22
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Ferner RE, Aronson JK. Nominal ISOMERs (Incorrect Spellings Of Medicines Eluding Researchers)-variants in the spellings of drug names in PubMed: a database review. BMJ 2016; 355:i4854. [PMID: 27974346 PMCID: PMC5156610 DOI: 10.1136/bmj.i4854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine how misspellings of drug names could impede searches for published literature. DESIGN Database review. DATA SOURCE PubMed. REVIEW METHODS The study included 30 drug names that are commonly misspelt on prescription charts in hospitals in Birmingham, UK (test set), and 30 control names randomly chosen from a hospital formulary (control set). The following definitions were used: standard names-the international non-proprietary names, variant names-deviations in spelling from standard names that are not themselves standard names in English language nomenclature, and hidden reference variants-variant spellings that identified publications in textword (tw) searches of PubMed or other databases, and which were not identified by textword searches for the standard names. Variant names were generated from standard names by applying letter substitutions, omissions, additions, transpositions, duplications, deduplications, and combinations of these. Searches were carried out in PubMed (30 June 2016) for "standard name[tw]" and "variant name[tw] NOT standard name[tw]." RESULTS The 30 standard names of drugs in the test set gave 325 979 hits in total, and 160 hidden reference variants gave 3872 hits (1.17%). The standard names of the control set gave 470 064 hits, and 79 hidden reference variants gave 766 hits (0.16%). Letter substitutions (particularly i to y and vice versa) and omissions together accounted for 2924 (74%) of the variants. Amitriptyline (8530 hits) yielded 18 hidden reference variants (179 (2.1%) hits). Names ending in "in," "ine," or "micin" were commonly misspelt. Failing to search for hidden reference variants of "gentamicin," "amitriptyline," "mirtazapine," and "trazodone" would miss at least 19 systematic reviews. A hidden reference variant related to Christmas, "No-el", was rare; variants of "X-miss" were rarer. CONCLUSION When performing searches, researchers should include misspellings of drug names among their search terms.
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Affiliation(s)
- Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham B18 7QH, UK
- Institute of Clinical Science, University of Birmingham, Birmingham, UK
| | - Jeffrey K Aronson
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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23
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Tseng HY, Wen CF, Lee YL, Jeng KC, Chen PL. Dispensing errors from look-alike drug trade names. Eur J Hosp Pharm 2016; 25:96-99. [PMID: 31156995 DOI: 10.1136/ejhpharm-2016-001019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 10/28/2016] [Accepted: 10/31/2016] [Indexed: 11/04/2022] Open
Abstract
Objectives To improve patient safety, we investigated near-miss dispensing errors in our hospital and evaluated the effectiveness of specific preventive strategies. Methods The incidence and type of near-miss dispensing errors in a single hospital in Taiwan were identified in 2013. The causes of dispensing errors were analysed by consensus of an expert panel comprising a senior pharmacist on duty, a group leader in the pharmacy and an author. Because alphabetical trade names were routinely used in our pharmacy, they were used for similarity analysis. Trigram-2b and normalised edit distance (NED) were used to calculate orthographic similarity and distance measure, respectively. The correlation between drug-name confusion and dispensing errors was then studied. Preventive strategies, including the introduction of tall man letters, were completed at the end of 2013, and error data were then recollected in 2014. Differences between before and after the interventions were examined by t-test. Results Before the intervention, look-alike alphabetical names were the main cause of dispensing wrong medicine (134/202, 66.3%). The frequency of near-miss dispensing errors correlated significantly with drug-name similarity (p<0.01). After implementation of preventive strategies, dispensing errors due to drug-name confusion were reduced significantly (77/140, 55.0%, p=0.004). Conclusions The frequency of near-miss drug dispensing errors correlated with greater similarity or lower NED scores, and dispensing errors related to drug-name confusion were significantly reduced by our interventions. However, other dispensing errors might need to be investigated in order to prevent them.
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Affiliation(s)
- Hsiang-Yi Tseng
- Department of Pharmacy, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan.,Taichung County Pharmacists Association, Taichung, Taiwan
| | - Chen-Fan Wen
- Department of Medical Research, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - Ya-Lun Lee
- Department of Pharmacy, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan.,Taichung County Pharmacists Association, Taichung, Taiwan
| | - Kee-Ching Jeng
- Department of Pharmacy, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan.,Taichung County Pharmacists Association, Taichung, Taiwan
| | - Pei-Liang Chen
- Department of Pharmacy, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan.,Taichung County Pharmacists Association, Taichung, Taiwan
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24
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Trbovich PL, Hyland S. Responding to the challenge of look-alike, sound-alike drug names. BMJ Qual Saf 2016; 26:357-359. [PMID: 27555615 DOI: 10.1136/bmjqs-2016-005629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2016] [Indexed: 11/04/2022]
Affiliation(s)
- P L Trbovich
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.,Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, Toronto, Ontario, Canada
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25
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Sahli J, El Ghardallou M, Bougmiza I, Henchiri B, Limam M, Mejdoub R, Mtiraoui A, Ajmi T. [Safety evaluation of anticancer drugs circuit in a regional hospital in Tunisia]. Pan Afr Med J 2016; 23:30. [PMID: 27200135 PMCID: PMC4856518 DOI: 10.11604/pamj.2016.23.30.8600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 01/20/2016] [Indexed: 11/28/2022] Open
Abstract
Introduction Parmi les événements indésirables, ceux liés au circuit des médicaments occupent une place importante et risquent de causer un préjudice grave aux patients. Dans ce contexte, nous avons mené cette étude dans l'optique de décrire et d’évaluer le circuit des médicaments anticancéreux dans un hôpital régional tunisien. Méthodes Il s'agit d'une étude évaluative du risque lié aux médicaments anticancéreux, type « visite de risque » menée sur une période de 15 jours au cours de l'année 2014 au service de cancérologie de l'hôpital régional de Gafsa (Tunisie). Cette méthode d’évaluation est inspirée de celle conduite par le projet « SECURIMED » développé par le Comité de Coordination de l'Evaluation Clinique et de la Qualité en Aquitaine (CCECQA), en France. Résultats Dans notre étude, l'observation du circuit des médicaments anticancéreux a révélé certaines insuffisances. On a noté que la répartition des missions des différents acteurs est sujette parfois à des glissements de tâches. Un manque important ainsi que une inadéquation aux normes au niveau des équipements nécessaires pour la préparation et la protection des professionnels manipulant ces médicaments ont été également décelés. Conclusion La sécurisation du circuit des médicaments devrait être une priorité inscrite dans l'ensemble des démarches nationales et partagée par tous les intervenants et ce dans l'optique d'atteindre un objectif prémium: la qualité de la prise en charge globale et la sécurité des patients.
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Affiliation(s)
- Jihène Sahli
- Laboratoire de Recherche « LR12ES03 », Département de Médecine Familiale et Communautaire, Faculté de Médecine Ibn El Jazzar Sousse, Université de Sousse,Tunisie
| | - Meriam El Ghardallou
- Laboratoire de Recherche « LR12ES03 », Département de Médecine Familiale et Communautaire, Faculté de Médecine Ibn El Jazzar Sousse, Université de Sousse,Tunisie
| | - Iheb Bougmiza
- Laboratoire de Recherche « LR12ES03 », Département de Médecine Familiale et Communautaire, Faculté de Médecine Ibn El Jazzar Sousse, Université de Sousse,Tunisie
| | - Besma Henchiri
- Service de Carcinologie, Hôpital Régional de Gafsa, Tunisie
| | - Manel Limam
- Laboratoire de Recherche « LR12ES03 », Département de Médecine Familiale et Communautaire, Faculté de Médecine Ibn El Jazzar Sousse, Université de Sousse,Tunisie
| | - Rim Mejdoub
- Service de Carcinologie, Hôpital Régional de Gafsa, Tunisie
| | - Ali Mtiraoui
- Laboratoire de Recherche « LR12ES03 », Département de Médecine Familiale et Communautaire, Faculté de Médecine Ibn El Jazzar Sousse, Université de Sousse,Tunisie
| | - Thouraya Ajmi
- Laboratoire de Recherche « LR12ES03 », Département de Médecine Familiale et Communautaire, Faculté de Médecine Ibn El Jazzar Sousse, Université de Sousse,Tunisie
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26
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Schroeder SR, Salomon MM, Galanter WL, Schiff GD, Vaida AJ, Gaunt MJ, Bryson ML, Rash C, Falck S, Lambert BL. Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains. BMJ Qual Saf 2016; 26:395-407. [PMID: 27193033 PMCID: PMC5530327 DOI: 10.1136/bmjqs-2015-005099] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 04/21/2016] [Accepted: 04/22/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Drug name confusion is a common type of medication error and a persistent threat to patient safety. In the USA, roughly one per thousand prescriptions results in the wrong drug being filled, and most of these errors involve drug names that look or sound alike. Prior to approval, drug names undergo a variety of tests to assess their potential for confusability, but none of these preapproval tests has been shown to predict real-world error rates. OBJECTIVES We conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates. METHODS Eighty participants, comprising doctors, nurses, pharmacists, technicians and lay people, completed a battery of laboratory tests assessing visual perception, auditory perception and short-term memory of look-alike and sound-alike drug name pairs (eg, hydroxyzine/hydralazine). RESULTS Laboratory test error rates (and other metrics) significantly predicted real-world error rates obtained from a large, outpatient pharmacy chain, with the best-fitting model accounting for 37% of the variance in real-world error rates. Cross-validation analyses confirmed these results, showing that the laboratory tests also predicted errors from a second pharmacy chain, with 45% of the variance being explained by the laboratory test data. CONCLUSIONS Across two distinct pharmacy chains, there is a strong and significant association between drug name confusion error rates observed in the real world and those observed in laboratory-based tests of memory and perception. Regulators and drug companies seeking a validated preapproval method for identifying confusing drug names ought to consider using these simple tests. By using a standard battery of memory and perception tests, it should be possible to reduce the number of confusing look-alike and sound-alike drug name pairs that reach the market, which will help protect patients from potentially harmful medication errors.
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Affiliation(s)
- Scott R Schroeder
- Center for Communication and Health, Department of Communication Studies, Northwestern University, Chicago, Illinois, USA
| | - Meghan M Salomon
- Department of Psychology, Northwestern University, Evanston, Illinois, USA
| | | | - Gordon D Schiff
- Department of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Allen J Vaida
- Institute for Safe Medication Practices, Horsham, Pennsylvania, USA
| | - Michael J Gaunt
- Institute for Safe Medication Practices, Horsham, Pennsylvania, USA
| | - Michelle L Bryson
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Christine Rash
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Suzanne Falck
- Department of Medicine, University of Illinois, Chicago, USA
| | - Bruce L Lambert
- Center for Communication and Health, Department of Communication Studies, Northwestern University, Chicago, Illinois, USA
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27
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Basco WT, Garner SS, Ebeling M, Freeland KD, Hulsey TC, Simpson K. Evaluating the Potential Severity of Look-Alike, Sound-Alike Drug Substitution Errors in Children. Acad Pediatr 2016; 16:183-91. [PMID: 26946271 PMCID: PMC4852303 DOI: 10.1016/j.acap.2015.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 06/24/2015] [Accepted: 06/25/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Look-alike, sound-alike (LASA) drug name substitution errors in children may pose potentially severe consequences. Our objective was to determine the degree of potential harm pediatricians ascribe to specific ambulatory LASA drug substitution errors. METHODS We developed a unified list of LASA pairs from published sources, removing selected drugs on the basis of preparation type (eg, injectable drugs). Using a modified Delphi method over 3 rounds, 38 practicing pediatricians estimated degree of potential harm that might occur should a patient receive the delivered drug in error and the degree of potential harm that might occur from not receiving the intended drug. RESULTS We identified 3550 published LASA drug pairs. A total of 1834 pairs were retained for the Delphi surveys, and 608 drug pairs were retained for round 3. Final scoring demonstrated that participants were able to identify pairs where the substitutions represented high risk of harm for receiving the delivered drug in error (eg, did not receive methylphenidate/received methadone), high risk of harm for not receiving the intended drug (eg, did not receive furosemide/received fosinopril), and pairs where the potential harm was high from not receiving the intended drug and from erroneously receiving the delivered drug (eg, did not receive albuterol/received labetalol). CONCLUSIONS Pediatricians have identified LASA drug substitutions that pose a high potential risk of harm to children. These results will allow future efforts to prioritize pediatric LASA errors that can be screened prospectively in outpatient pharmacies.
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Affiliation(s)
- William T Basco
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC.
| | - Sandra S Garner
- Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Charleston, SC
| | - Myla Ebeling
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC
| | - Katherine D Freeland
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC
| | - Thomas C Hulsey
- Department of Epidemiology, West Virginia University, Morgantown, WV
| | - Kit Simpson
- Department of Health Administration and Policy, College of Health Professions, The Medical University of South Carolina, Charleston, SC
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Tsuji T, Irisa T, Ohata S, Kokubu C, Kanaya A, Sueyasu M, Egashira N, Masuda S. Relationship between incident types and impact on patients in drug name errors: a correlational study. J Pharm Health Care Sci 2016; 1:11. [PMID: 26819722 PMCID: PMC4729157 DOI: 10.1186/s40780-015-0011-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/04/2015] [Indexed: 11/10/2022] Open
Abstract
Background There are many reports regarding various medical institutions’ attempts at incident prevention, but the relationship between incident types and impact on patients in drug name errors has not been studied. Therefore, we analyzed the relationship between them, while also assessing the relationship between preparation and inspection errors. Furthermore, the present study aimed to clarify the incident types that lead to severe patient damage. Methods The investigation object in this study was restricted to “drug name errors”, preparation and inspection errors in them were classified into three categories (similarity of drug efficacy, similarity of drug name, similarity of drug appearance) or two groups (drug efficacy similarity (+) group, drug efficacy similarity (−) group). Then, the relationship between preparation and inspection errors was investigated in three categories, the relationship between incident types and impact on patients was examined in two groups. Results The frequency of preparation errors was liable to be caused by the following order: similarity of drug efficacy > similarity of drug name > similarity of drug appearance. In contrast, the rate of inspection errors was liable to be caused by the following order: similarity of drug efficacy < similarity of drug name < similarity of drug appearance. In addition, the number of preparation errors in the drug efficacy similarity (−) group was fewer than that in the drug efficacy similarity (+) group. However, the rate of inspection errors in the drug efficacy similarity (−) group was significantly higher than that in the drug efficacy similarity (+) group. Furthermore, the occupancy rate of preparation errors, incidents more than Level 0, 1, and 2 in the drug efficacy similarity (−) group increased gradually according to the rise of patient damage. Conclusions Our results suggest that preparation errors caused by the similarity of drug appearance and/or drug name are likely to lead to the incidents (inspection errors), and these incidents are likely to cause severe damage to patients subsequently. Electronic supplementary material The online version of this article (doi:10.1186/s40780-015-0011-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toshikazu Tsuji
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Toshihiro Irisa
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Shunichi Ohata
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Chiyo Kokubu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Akiko Kanaya
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Masanori Sueyasu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Nobuaki Egashira
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Satohiro Masuda
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
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DeHenau C, Becker MW, Bello NM, Liu S, Bix L. Tallman lettering as a strategy for differentiation in look-alike, sound-alike drug names: the role of familiarity in differentiating drug doppelgangers. APPLIED ERGONOMICS 2016; 52:77-84. [PMID: 26360197 DOI: 10.1016/j.apergo.2015.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 04/27/2015] [Accepted: 06/07/2015] [Indexed: 06/05/2023]
Abstract
Tallman lettering, capitalizing the dissimilar portions of easily confused drug names, is one strategy for reducing medication errors. We assessed the efficacy of Tallman lettering in a visually complex environment using a change detection method with healthcare providers and laypeople. In addition, the effect of familiarity with the drug name was assessed using a subset of responses collected from healthcare providers. Both healthcare providers and laypeople detected changes in confusable pairs of drug names more often (P < 0.0001) and more quickly (P < 0.05) when changes were presented in Tallman lettering, though the benefits were more pronounced for healthcare providers (p < 0.05). Familiarity with both drug names in a confusable pair mitigated the benefit of Tallman lettering. Results are discussed in terms of bottom-up and top-down attentional systems for processing of information in the context of the varied healthcare environments.
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Affiliation(s)
- Carly DeHenau
- School of Packaging, Michigan State University, East Lansing, MI 48824, USA
| | - Mark W Becker
- Cognition and Cognitive Neuroscience Group, Psychology, Michigan State University, East Lansing, MI 48824, USA
| | - Nora M Bello
- Department of Statistics, Kansas State University, Manhattan, KS 66506, USA
| | - Sichang Liu
- School of Packaging, Michigan State University, East Lansing, MI 48824, USA
| | - Laura Bix
- School of Packaging, Michigan State University, East Lansing, MI 48824, USA.
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Stockbridge MD, Taylor K. A Method of Addressing Proprietary Name Similarity for US Prescription Drugs. Ther Innov Regul Sci 2015; 49:524-529. [PMID: 30222425 DOI: 10.1177/2168479015570331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is an increased risk of medication error and harm to a patient whenever 2 or more drug product names appear alike in sound, look, or meaning. Any ambiguity of the proprietary name ("trade" or "brand" name) of a drug product can lead to errors in ordering, dispensing, or administering medication. A drug's name is a critical identifier, and correct product identification is important to the responsible administration of medicine. This article describes a series of tools created for regulatory reviewers to enhance the review of proprietary names under current federal regulations, with the goal of encouraging further innovation toward the goal of medication safety. These tools include measures of orthographic, phonetic, and semantic similarities and are designed be used together with the existing computerized measures of similarity. It is the hope that highlighting the importance of medication error reporting for the safety review process will further encourage health care professionals to provide adequate and detailed reporting regarding medication errors, which will lead to improvements in the overall safety review process.
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Affiliation(s)
| | - Kellie Taylor
- 2 Center for Drug Evaluation and Research Division of Medication Error Prevention and Analysis, White Oak, MD, USA
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Bryan R, Aronson JK, ten Hacken P, Williams A, Jordan S. Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names. PLoS One 2015; 10:e0145431. [PMID: 26701761 PMCID: PMC4689353 DOI: 10.1371/journal.pone.0145431] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 12/03/2015] [Indexed: 01/26/2023] Open
Abstract
Background Confusion between look-alike and sound-alike (LASA) medication names (such as mercaptamine and mercaptopurine) accounts for up to one in four medication errors, threatening patient safety. Error reduction strategies include computerized physician order entry interventions, and ‘Tall Man’ lettering. The purpose of this study is to explore the medication name designation process, to elucidate properties that may prime the risk of confusion. Methods and Findings We analysed the formal and semantic properties of 7,987 International Non-proprietary Names (INNs), in relation to naming guidelines of the World Health Organization (WHO) INN programme, and have identified potential for errors. We explored: their linguistic properties, the underlying taxonomy of stems to indicate pharmacological interrelationships, and similarities between INNs. We used Microsoft Excel for analysis, including calculation of Levenshtein edit distance (LED). Compliance with WHO naming guidelines was inconsistent. Since the 1970s there has been a trend towards compliance in formal properties, such as word length, but longer names published in the 1950s and 1960s are still in use. The stems used to show pharmacological interrelationships are not spelled consistently and the guidelines do not impose an unequivocal order on them, making the meanings of INNs difficult to understand. Pairs of INNs sharing a stem (appropriately or not) often have high levels of similarity (<5 LED), and thus have greater potential for confusion. Conclusions We have revealed a tension between WHO guidelines stipulating use of stems to denote meaning, and the aim of reducing similarities in nomenclature. To mitigate this tension and reduce the risk of confusion, the stem system should be made clear and well ordered, so as to avoid compounding the risk of confusion at the clinical level. The interplay between the different WHO INN naming principles should be further examined, to better understand their implications for the problem of LASA errors.
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Affiliation(s)
- Rachel Bryan
- Swansea University, Swansea, Wales, United Kingdom
- * E-mail:
| | - Jeffrey K. Aronson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Pius ten Hacken
- Institute for Translation Studies, University of Innsbruck, Innsbruck, Austria
| | | | - Sue Jordan
- Swansea University, Swansea, Wales, United Kingdom
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Zinn TE, Newland MC, Ritchie KE. The efficiency and efficacy of equivalence-based learning: A randomized controlled trial. J Appl Behav Anal 2015; 48:865-82. [DOI: 10.1002/jaba.258] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 04/22/2015] [Indexed: 11/06/2022]
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Tsuji T, Irisa T, Tagawa S, Kawashiri T, Ikesue H, Kokubu C, Kanaya A, Egashira N, Masuda S. Differences in recognition of similar medication names between pharmacists and nurses: a retrospective study. J Pharm Health Care Sci 2015; 1:19. [PMID: 26819730 PMCID: PMC4728788 DOI: 10.1186/s40780-015-0017-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/21/2015] [Indexed: 11/23/2022] Open
Abstract
Background Differences in error rates between pharmacists and nurses in terms of drug confirmation have not been studied. The purpose of this study was to analyze differences in error rates between pharmacists and nurses from the viewpoint of error categories, and to clarify differences in recognition regarding drug name similarity. Methods In this study, preparation errors and incidents were classified into three categories (drug strength errors, drug name errors, and drug count errors) to investigate the influence of error categories on pharmacists and nurses. In addition, errors in two categories (drug strength errors and drug name errors) were reclassified into another two error groups, to investigate the influence of drug name similarity on pharmacists and nurses: a “drug name similarity (−) group” and a “drug name similarity (+) group”. Then, differences in error rates of pharmacists and those of nurses were analyzed respectively within three categories and two groups. Furthermore, differences in error rates between pharmacists and nurses were analyzed in each of the three categories and two groups. Results Error rates of pharmacists for both drug strength errors and drug name errors were significantly higher than that for drug count errors, and similar results were obtained for nurses (P < 0.05). However, there were no significant differences in error rates between pharmacists and nurses in each of the three categories. Furthermore, error rate of nurses was significantly higher than that of pharmacists in the drug name similarity (+) group (P < 0.05), while there was no significant difference in error rates between pharmacists and nurses in the drug name similarity (−) group. Conclusions These results suggest that in contrast to pharmacists, nurses are easily affected by similarities in drug names. Therefore, pharmacists should offer information on medications having plural strengths or similar names to nurses, in order to minimize damage to patients resulting from errors. Electronic supplementary material The online version of this article (doi:10.1186/s40780-015-0017-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toshikazu Tsuji
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Toshihiro Irisa
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Shinji Tagawa
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Takehiro Kawashiri
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Hiroaki Ikesue
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Chiyo Kokubu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Akiko Kanaya
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Nobuaki Egashira
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Satohiro Masuda
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
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Milton RM, Washington NB, Brahm N. Hypoglycemia from a look-alike, sound-alike medication error. Ment Health Clin 2015. [DOI: 10.9740/mhc.2015.07.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
To describe the effects of a look-alike, sound-alike medication error on the glycemic control and psychiatric well-being of a 23-year-old man.
Case Summary
A 23-year-old man presented to the university-based Integrated Multidisciplinary Program of Assertive Community Treatment (IMPACT) team with a diagnosis of schizoaffective disorder, most recent episode manic, and hypertension. The patient was prescribed chlorpromazine 100 mg daily to treat symptoms of psychosis and anxiety. The anxiety, however, persisted and escalated over the following 2 weeks. Upon physical examination of the patient's medications, it was discovered that the patient was inadvertently given chlorpropamide in place of the chlorpromazine. Evaluations, clinical presentation, the medication list, and criteria for an adverse drug event indicated a probable relationship (7 of 12) between the use of chlorpropamide and a hypoglycemic episode. The medication error was noted and corrective actions were taken. Within 1 week of the corrective actions, the patient's anxiety improved.
Discussion
When working with psychiatric patients, it is important to physically review all medications when expected responses are not achieved or when new psychiatric or physiological symptoms present. Approximately one-fourth of medication errors in the United States are drug name confusion errors. These errors must be universally addressed by all parties involved in the medication process. Effective safeguards are available and must be implemented by manufacturers, physicians, pharmacists, nurses, and all health care professionals to prevent look-alike, sound-alike medication errors.
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Affiliation(s)
- Robin M. Milton
- Clinical Assistant Professor, College of Pharmacy, University of Oklahoma, Tulsa, Oklahoma
| | - Nicole B. Washington
- Assistant Professor, Department of Psychiatry, School of Community Medicine, University of Oklahoma, Tulsa, Oklahoma
| | - Nancy Brahm
- (Corresponding author) Clinical Professor, College of Pharmacy, University of Oklahoma, Tulsa, Oklahoma,
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Lambert BL, Bhaumik R, Zhao W, Bhaumik DK. Detection and prediction limits for identifying highly confusable drug names from experimental data. J Biopharm Stat 2015; 26:365-85. [DOI: 10.1080/10543406.2015.1052481] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Indication alerts intercept drug name confusion errors during computerized entry of medication orders. PLoS One 2014; 9:e101977. [PMID: 25025346 PMCID: PMC4098994 DOI: 10.1371/journal.pone.0101977] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 06/13/2014] [Indexed: 11/19/2022] Open
Abstract
Background Confusion between similar drug names is a common cause of potentially harmful medication errors. Interventions to prevent these errors at the point of prescribing have had limited success. The purpose of this study is to measure whether indication alerts at the time of computerized physician order entry (CPOE) can intercept drug name confusion errors. Methods and Findings A retrospective observational study of alerts provided to prescribers in a public, tertiary hospital and ambulatory practice with medication orders placed using CPOE. Consecutive patients seen from April 2006 through February 2012 were eligible if a clinician received an indication alert during ordering. A total of 54,499 unique patients were included. The computerized decision support system prompted prescribers to enter indications when certain medications were ordered without a coded indication in the electronic problem list. Alerts required prescribers either to ignore them by clicking OK, to place a problem in the problem list, or to cancel the order. Main outcome was the proportion of indication alerts resulting in the interception of drug name confusion errors. Error interception was determined using an algorithm to identify instances in which an alert triggered, the initial medication order was not completed, and the same prescriber ordered a similar-sounding medication on the same patient within 5 minutes. Similarity was defined using standard text similarity measures. Two clinicians performed chart review of all cases to determine whether the first, non-completed medication order had a documented or non-documented, plausible indication for use. If either reviewer found a plausible indication, the case was not considered an error. We analyzed 127,458 alerts and identified 176 intercepted drug name confusion errors, an interception rate of 0.14±.01%. Conclusions Indication alerts intercepted 1.4 drug name confusion errors per 1000 alerts. Institutions with CPOE should consider using indication prompts to intercept drug name confusion errors.
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Look alike/sound alike drugs: a literature review on causes and solutions. Int J Clin Pharm 2013; 36:233-42. [DOI: 10.1007/s11096-013-9885-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 11/11/2013] [Indexed: 10/26/2022]
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Feldman R, Lobo F. Competition in prescription drug markets: the roles of trademarks, advertising, and generic names. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2013; 14:667-675. [PMID: 22815099 DOI: 10.1007/s10198-012-0414-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 07/03/2012] [Indexed: 06/01/2023]
Abstract
We take on two subjects of controversy among economists-advertising and trademarks-in the context of the market for generic drugs. We outline a model in which trademarks for drug names reduce search costs but increase product differentiation. In this particular framework, trademarks may not benefit consumers. In contrast, the generic names of drugs or "International Nonproprietary Names" (INN) have unquestionable benefits in both economic theory and empirical studies. We offer a second model where advertising of a brand-name drug creates recognition for the generic name. The monopoly patent-holder advertises less than in the absence of a competitive spillover.
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Samaranayake N, Cheung S, Chui W, Cheung B. Technology-related medication errors in a tertiary hospital: A 5-year analysis of reported medication incidents. Int J Med Inform 2012; 81:828-33. [DOI: 10.1016/j.ijmedinf.2012.09.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 09/06/2012] [Accepted: 09/07/2012] [Indexed: 10/27/2022]
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Savill NJ, Thierry G. Electrophysiological evidence for impaired attentional engagement with phonologically acceptable misspellings in developmental dyslexia. Front Psychol 2011; 2:139. [PMID: 21734903 PMCID: PMC3124829 DOI: 10.3389/fpsyg.2011.00139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 06/09/2011] [Indexed: 11/13/2022] Open
Abstract
Event-related potential (ERP) studies of word recognition have provided fundamental insights into the time-course and stages of visual and auditory word form processing in reading. Here, we used ERPs to track the time-course of phonological processing in dyslexic adults and matched controls. Participants engaged in semantic judgments of visually presented high-cloze probability sentences ending either with (a) their best completion word, (b) a homophone of the best completion, (c) a pseudohomophone of the best completion, or (d) an unrelated word, to examine the interplay of phonological and orthographic processing in reading and the stage(s) of processing affected in developmental dyslexia. Early ERP peaks (N1, P2, N2) were modulated in amplitude similarly in the two groups of participants. However, dyslexic readers failed to show the P3a modulation seen in control participants for unexpected homophones and pseudohomophones (i.e., sentence completions that are acceptable phonologically but are misspelt). Furthermore, P3a amplitudes significantly correlated with reaction times in each experimental condition. Our results showed no sign of a deficit in accessing phonological representations during reading, since sentence primes yielded phonological priming effects that did not differ between participant groups in the early phases of processing. On the other hand, we report new evidence for a deficient attentional engagement with orthographically unexpected but phonologically expected words in dyslexia, irrespective of task focus on orthography or phonology. In our view, this result is consistent with deficiency in reading occurring from the point at which attention is oriented to phonological analysis, which may underlie broader difficulties in sublexical decoding.
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Affiliation(s)
| | - Guillaume Thierry
- School of Psychology, Bangor UniversityBangor, UK
- Economic and Social Research Council Centre for Research on Bilingualism in Theory and Practice, Bangor UniversityBangor, UK
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Khadem NR, Nirenberg MJ. Carbidopa/levodopa pharmacy errors in Parkinson's disease. Mov Disord 2011; 25:2867-71. [PMID: 20818662 DOI: 10.1002/mds.23311] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Outpatient pharmacy errors are common, but little is known about their occurrence in Parkinson's disease (PD). We prospectively studied carbidopa/levodopa pharmacy errors in a cohort of PD outpatients. Over 1 year, pharmacy errors occurred in 8/73 (11%) subjects treated with this medication, producing adverse drug events (ADEs) in 7/8 (87.5%) and increased healthcare utilization in 6/8 (75%) cases. The most common errors were substitution of controlled-release for immediate-release carbidopa/levodopa 25/100 mg (5/8; 62.5%) or dispensation of the wrong carbidopa/levodopa dosage (2/8; 25%). All errors involved ongoing prescriptions, including three interpharmacy transfers. Three subjects (37.5%) questioned pharmacy staff about the change in appearance of the tablets, but the error was corrected in only 1/3 of these cases. Carbidopa/levodopa outpatient pharmacy errors are a common, preventable cause of morbidity and excessive healthcare utilization in PD. Education of healthcare providers, patients, and pharmacy staff is warranted to reduce these errors and associated ADEs.
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Affiliation(s)
- Nasim R Khadem
- Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, New York, USA
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Savill NJ, Thierry G. Reading for sound with dyslexia: Evidence for early orthographic and late phonological integration deficits. Brain Res 2011; 1385:192-205. [DOI: 10.1016/j.brainres.2011.02.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 01/26/2011] [Accepted: 02/03/2011] [Indexed: 11/30/2022]
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Anto B, Barlow D, Oborne CA, Whittlesea C. Incorrect drug selection at the point of dispensing: a study of potential predisposing factors. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2011; 19:51-60. [DOI: 10.1111/j.2042-7174.2010.00072.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Objective
To determine potential predisposing factors to medication errors involving confusion between drug names, strengths and dosage forms.
Methods
The study analysed medication errors reported over the period January 2005 to December 2008 from the two main dispensaries of a 1200-bed NHS Foundation Hospital Trust in London. Dispensing incidents considered for analysis included all incidents involving drug name, strength and dosage label and content errors. Statistical analyses were performed using Statistica. Dispensing frequencies of the prescribed and wrongly dispensed drugs were compared by means of Wilcoxon signed-rank test, and the extent of correlation between dispensing frequency and error frequency was assessed using Spearman's rank correlation coefficient.
Key findings
The Trust recorded a total of 911 dispensing errors between 2005 and 2008. The most significant category, which accounted for 211 (23.2%) of the reported errors, involved errors in drug selection. Drug-selection errors were not random events because the plot of error frequency against the average yearly dispensing frequency for the 1000 most issued drugs showed little evidence of association (r = 0.19, P(α) = 0.03). There was, however, an increased likelihood of drug-selection errors occurring when the prescribed drug was dispensed with relatively low frequency and shows a significant orthographic similarity to another drug which has a higher dispensing frequency.
Conclusion
The majority of drug-selection errors would seem to be caused by insufficient attention paid to the specified drug strength. Dispensing frequency is an important factor influencing the likelihood of a drug-selection errors occurring, but it is also shown here that a large proportion of the drug-selection errors involved specifications exhibiting high orthographic similarity.
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Affiliation(s)
- Berko Anto
- Institute of Pharmaceutical Science, King's College London, UK
| | - David Barlow
- Institute of Pharmaceutical Science, King's College London, UK
| | - C Alice Oborne
- Guy's and St Thomas' NHS hospital Foundation Trust, London, UK
| | - Cate Whittlesea
- Institute of Pharmaceutical Science, King's College London, UK
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Trudeau M, Green E, Cosby R, Charbonneau F, Easty T, Ko Y, Marchand P, David U, Berger N, Hertz S. Key components of intravenous chemotherapy labeling: A systematic review and practice guideline. J Oncol Pharm Pract 2010; 17:409-24. [DOI: 10.1177/1078155210385160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective. To determine the necessary components and formatting of an intravenous chemotherapy label to maximize safe delivery and minimize errors. Date sources. The MEDLINE and EMBASE databases (up to April 2009) were searched for relevant evidence. Reference lists from retained studies were then searched for additional trials. An environmental scan was also conducted to locate other published and unpublished sources of information. Study selection. Relevant articles were selected and reviewed by one methodologist. Articles were selected for inclusion if they were published English language reports of Phases II or III randomized controlled trials, other comparative studies, single-arm studies, practice guidelines, or systematic reviews with or without meta-analyses, which related to the study question. MEDLINE and EMBASE searches yielded 685 potential studies of which 17 met the inclusion criteria. The environmental scan located one guideline. Three additional relevant studies were identified during the external review process. In total, 21 documents met the inclusion criteria. Data extraction. Data were extracted by one methodologist. Quality of systematic reviews was assessed using the AMSTAR tool. All other studies were evaluated based on study characteristics applicable to the particular study design. Data synthesis. The evidence collected and the consensus of expert opinion of Cancer Care Ontario’s Chemotherapy Labeling Panel form the basis of a series of recommendations for the generation of intravenous chemotherapy labels including formatting, required information, and order of information. These guidelines inform the efficient, effective, and safe administration of intravenous chemotherapy. Illustrative examples are provided.
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Affiliation(s)
- Maureen Trudeau
- Odette Cancer Centre; Sunnybrook Health Science Centre; Cancer Care Ontario, Toronto, ON, Canada
| | | | - Roxanne Cosby
- Cancer Care Ontario’s Program in Evidence-Based Care; Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Tony Easty
- Centre for Global eHealth Innovation; University of Toronto; University Health Network, Toronto, ON, Canada
| | - Yooj Ko
- Odette Cancer Centre, Toronto, ON, Canada
| | - Patti Marchand
- RS McLaughlin Durham Regional Cancer Centre, Oshawa, ON, Canada
| | - U David
- Institute for Safe Medication Practices Canada, Toronto, ON, Canada
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Basco WT, Ebeling M, Hulsey TC, Simpson K. Using pharmacy data to screen for look-alike, sound-alike substitution errors in pediatric prescriptions. Acad Pediatr 2010; 10:233-7. [PMID: 20541485 DOI: 10.1016/j.acap.2010.04.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 04/23/2010] [Accepted: 04/27/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of this study was to pilot test a screening approach to detect potential look-alike, sound-alike (LASA) errors in pediatric outpatient prescriptions. METHOD Medicaid pharmacy claims from one state were reviewed. From a list of LASA drug pairs, we identified candidate pairs meeting the following criteria: 1) one drug was commonly prescribed in children; 2) the paired drug was uncommonly prescribed for children; and 3) both drugs were available as oral preparations only, resulting in 11 LASA pairs. We identified patients who usually received one drug in a pair, then presented with a first dispensing of the paired drug, representing a "screening alert" for potential LASA error. We determined a "true error" as any patient who triggered a screening alert, received only one dispensing of the paired drug in the subsequent 6 months, and had no diagnoses supporting the dispensing of the paired drug. RESULTS Among the 22 test drugs, there were 1 420 091 prescriptions to 173 005 subjects. There were 395 screening alerts generated, representing a screening alert frequency of 0.28 screening alerts per 1000 prescriptions. We identified 43 true LASA errors. In the dataset, the overall LASA error rate is estimated to be approximately 0.00003%, or 0.03 LASA errors per 1000 prescriptions. CONCLUSION Prescription dispensing patterns can be used to screen for LASA errors in pediatric prescriptions. The rates of pediatric LASA errors appear to be much lower than other types of pediatric medication errors and may be best addressed by automated processes.
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Affiliation(s)
- William T Basco
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.
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Lambert BL, Dickey LW, Fisher WM, Gibbons RD, Lin SJ, Luce PA, McLennan CT, Senders JW, Yu CT. Listen carefully: The risk of error in spoken medication orders. Soc Sci Med 2010; 70:1599-608. [DOI: 10.1016/j.socscimed.2010.01.042] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 11/23/2009] [Accepted: 01/20/2010] [Indexed: 11/25/2022]
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James KL, Barlow D, Burfield R, Hiom S, Roberts D, Whittlesea C. A study of unprevented dispensing incidents in Welsh NHS hospitals. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2010. [DOI: 10.1211/ijpp.16.3.0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
Objective
To monitor unprevented dispensing incidents in NHS hospitals by identifying incident types, drugs involved and factors that may have contributed to the occurrence of incidents.
Setting
All 20 Welsh NHS hospitals (15 district general; 2 teaching; 2 psychiatric and 1 other specialist hospital).
Method
Unprevented dispensing incidents that occurred between January 2003 and December 2004 were reported and analysed using a validated method. Incident rate was calculated for those hospitals that provided both incident and issue data. Incident rate was compared with previous research using a two-sample t-test. Reported incident types and contributory factors were compared with previous research using chi-square analysis.
Key findings
A total of 1005 unprevented dispensing incidents were reported by 20 hospitals. The overall incident rate, based on data from 17 hospitals, was 16 incidents per 100000 items dispensed (range 0.2–46 incidents per 100000 items dispensed). The overall dispensing incident rate was less than previously reported (18 incidents per 100000 items dispensed).This finding was not statistically significant (t = 0.421, P = 0.676). The most common incidents reported were dispensing the wrong strength of drug (n = 241, 24%), wrong drug (n = 168, 17%), wrong form (n = 134, 13%) and printing the wrong warnings/directions on the label (n = 112, 11%). A statistically significant finding was that fewer incidents involving dispensing the wrong drug were reported by Welsh hospitals (17%) compared to previous research in the UK (23%; P = 0.01). Drugs most commonly involved in incidents were insulin (n = 34; 6 incidents per 10000 issues of insulin), nifedipine (n = 16; 10 incidents per 10000 issues of nifedipine) and carbamazepine (n = 10; 5 incidents per 10000 issues of carbamazepine).
Conclusion
The overall unprevented dispensing incident rate was less than previously reported. Dispensing the wrong strength of the correct drug is a problem. Staff should be aware of the risk of dispensing incidents involving insulin, nifedipine and carbamazepine. Strategies for minimising dispensing incidents include using shelf labels to highlight different strengths or formulations of the same drug, and educating staff about easily confused drugs.
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Affiliation(s)
| | | | | | - Sarah Hiom
- St Mary's Pharmaceutical Unit, Cardiff and Vale NHS Trust
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Chen LC, Chen CH, Chen HM, Tseng VS. Hybrid data mining approaches for prevention of drug dispensing errors. J Intell Inf Syst 2009. [DOI: 10.1007/s10844-009-0107-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Barzdo M, Zydek L, Smedra-Kaźmirska A, Zgoda M, Machała W, Berent J. Erroneous administration of vinblastine. PHARMACY WORLD & SCIENCE : PWS 2009; 31:362-364. [PMID: 19306070 DOI: 10.1007/s11096-009-9291-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 03/11/2009] [Indexed: 05/27/2023]
Abstract
This case describes a series of errors which resulted in an avoidable death of the patient. Upon being presented with the 83-year-old patient and her complaints, the physician in charge attempted to prescribe Vasolastine (a complex preparation used, for example, in treatment of angiopathy, which is administered intramuscularly once a day). Unfortunately he misspelled the name of the medicine as Vinplastyna--a non-existent preparation. When the patient's daughter went to collect the prescription from the pharmacist she was dispensed Vinblastin (vinblastine--a cytostatic medicine used, for example, in treating Hodgkin's disease, non-Hodgkin's lymphoma, chronic lymphatic leukemia and testicular cancer). The visiting community nurses administered a dose of this medicine on seven consecutive days. Upon being given the seventh dose, the patient displayed symptoms of myelophthisis, and was admitted to an Intensive Care Ward, where despite the treatment, she died.
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Affiliation(s)
- Maciej Barzdo
- Department of Forensic Court and Insurance Certification, Medical University of Lodz, ul. Sedziowska 18a, 91-304, Lodz, Poland
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