A Comparison of the Effects of Different Typographical Methods on the Recognizability of Printed Drug Names

Medication errors in veterinary anesthesia: a literature review

OBJECTIVE

To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction.

DATABASES USED

PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗].

CONCLUSIONS

Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation

BACKGROUND

Patients in intensive care units are prone to the occurrence of medication errors. Look-alike, sound-alike drugs with similar drug names can lead to medication errors and therefore endanger patient safety. Capitalisation of distinct text parts in drug names might facilitate differentiation of medication labels. The aim of this study was to test whether the use of such 'tall man' lettering (TML) reduces the error rate and to examine effects on the visual attention of critical care nurses while identifying syringe labels.

METHODS

This was a prospective, randomised in situ simulation conducted at the University Hospital Zurich, Zurich, Switzerland. Under observation by eye tracking, 30 nurses were given 10 successive tasks involving the presentation of a drug name and its selection from a dedicated set of 10 labelled syringes that included look-alike and sound-alike drug names, half of which had TML-coded labels.Error rate as well as dwell time, fixation count, fixation duration and revisits were analysed using a linear mixed-effects model analysis to compare TML-coded with non-TML-coded labels.

RESULTS

TML coding of syringe labels led to a significant decrease in the error rate (from 5.3% (8 of 150 in non-TML-coded sets) to 0.7% (1 of 150 in TML-coded sets), p<0.05). Eye tracking further showed that TML affects visual attention, resulting in longer dwell time (p<0.01), more and longer fixations (p<0.05 and p<0.01, respectively) on the drug name as well as more frequent revisits (p<0.01) compared with non-TML-coded labels. Detailed analysis revealed that these effects were stronger for labels using TML in the mid-to-end position of the drug name.

CONCLUSIONS

TML in drug names changes visual attention while identifying syringe labels and supports critical care nurses in preventing medication errors.

Interventions to Reduce Problems Related to the Readability and Comprehensibility of Drug Packages and Labels: A Systematic Review

OBJECTIVE

The aim of the study was to evaluate the effectiveness of interventions designed to reduce problems with readability and comprehensibility in drug labels.

METHODS

A systematic review of observational and experimental studies was conducted using MEDLINE (via PubMed), Embase, and Scopus databases. Two independent reviewers selected articles and collected data about study design, interventions, and outcomes.

RESULTS

Of 1786 studies screened, 17 were included in this systematic review. The main findings were described according to the type of intervention in the drug package or label: color-coded labels (7 studies); changes in information layout (5 studies); changes in font size (3 studies); and interventions involving look-alike/sound-alike (LASA) drugs (3 studies). Color changes were important both for healthcare professionals to improve safety in hospital practice and for medication users to differentiate between the types of insulin. Layout changes were effective and included highlighting key information, such as medication name, dose, and instructions. Increased font size yielded good results in the recognition and identification of medications mainly for the population with impaired vision. This review was limited by the heterogeneity of interventions and populations studied, as well as the small number of high-quality studies, which prevented meta-analysis across any one intervention or outcome.

CONCLUSIONS

All studies reported positive results for the proposed interventions. In the case of LASA drug names, the use of resources beyond Tall Man lettering (such as color and highlighting) reduced recognition errors, which may contribute to the development of new strategies to improve safety in the use of LASA drugs.

Effects of Text Enhancement on Reduction of Look-Alike Drug Name Confusion: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Drug name confusion induced by look-alike drug names represents a serious health care management problem in practice. Text enhancement by changing visual attributes of look-alike drug names has been proposed and widely applied in practice to mitigate drug name confusion. However, the effectiveness of text enhancement on reducing drug name confusion is yet to be determined. This study aimed to explore the effects of text enhancement on reduction of confusion caused by look-alike drug names through systematic review and meta-analysis.

METHODS

We searched 5 databases (from database inception to January 2020) for empirical studies that examined the effects of text enhancement on reduction of look-alike drug name-induced drug name confusion. The pooled outcome data were analyzed using either meta-analysis or a narrative synthesis approach.

RESULTS

From the 351 identified articles, 11 articles representing 20 individual trials were included. Five basic text enhancement methods were revealed, including Tall Man, red, boldface, contrast, and size enhancement, from which 4 Tall Man variants and 6 text enhancement combinations were derived. The meta-analysis results showed significant reduction in omission errors when using Tall Man (standardized mean difference [SMD] = -0.628, 95% confidence interval [CI]: -1.018 to -0.238, P = .002), red (SMD = -0.516, 95% CI: -1.002 to -0.030, P = .038), boldface (SMD = -1.027, 95% CI: -1.240 to -0.814, P < .001), and contrast (SMD = -0.437, 95% CI: -0.869 to -0.004, P = 0.048), as compared with lowercase. This finding was also supported in our subgroup analysis by task type for name differentiation tasks. No other significant effects of text enhancement were found for either commission errors or response time.

CONCLUSIONS

Using Tall Man, red, boldface, or contrast could help reduce omission errors (ie, wrong medication selection) caused by look-alike drug names, particularly in name differentiation tasks. However, no text enhancement could shorten name search and/or differentiation time. Our findings could facilitate the understanding of the effects of text enhancement in the prevention of confusion errors caused by look-alike drug names and promote the application of text enhancement in practice.

A systematic literature review of LASA error interventions

AIMS

The aim of this systematic review was to explore and evaluate the efficacy of interventions to reduce the prevalence of look-alike, sound-alike (LASA) medication name errors.

METHODS

We conducted a systematic review of the literature, searching PubMed, EMBASE, Scopus and Web of Science up to December 2016, and re-ran the search in February 2020 for later results. We included studies of interventions to reduce LASA errors and included randomized controlled trials, controlled before-and-after studies, and interrupted time series. Details were registered in Prospero (ID: CRD42016048198).

RESULTS

We identified six studies that fulfilled our inclusion criteria. All were conducted in laboratories. Given the diversity in the included studies, we did not conduct a meta-analysis and instead report the findings narratively. The only intervention explored in RCTs was capitalization of selected letters ("Tall Man"), for which we found limited efficacy and no consensus.

CONCLUSIONS

Tall Man lettering is a marginally effective intervention to reduce LASA errors, with a number of caveats. We suggest that Tall Man gives rise to a "quasi-placebo effect", whereby a user derives more benefit from Tall Man lettering if they are aware of its purpose.

Effects of Text Enhancement, Identical Prescription-Package Names, Visual Cues, and Verbal Provocation on Visual Searches of Look-Alike Drug Names: A Simulation and Eye-Tracking Study

OBJECTIVE

Simulation and eye tracking were used to examine the effects of text enhancement, identical prescription-package names, visual cues, and verbal provocation on visual searches of look-alike drug names.

BACKGROUND

Look-alike drug names can cause confusion and medication errors, which jeopardize patient safety. The effectiveness of many strategies that may prevent these problems requires evaluation.

METHOD

We conducted two experiments that were based on a four-way, repeated-measures design. The within-subject factors were text enhancement, identical prescription-package names, visual cues, and verbal provocation. In Experiment 1, 40 nurses searched for and selected a target drug from an array of drug packages on a pharmacy shelf mock-up. In Experiment 2, the eye movements of another 40 nurses were tracked while they performed a computer-based drug search task.

RESULTS

Text enhancement had no significant effect on the drug search. Nurses selected the target drugs more quickly and easily when the prescriptions and drug packages shared identical drug name formats. The use of a visual cue to direct nurses' attention facilitated their visual searches and improved their eye gaze behaviors. The nurses reported greater mental effort if they were provoked verbally during the drug search.

CONCLUSION

Efficient and practical strategies should be adopted for designs that facilitate accurate drug search. Among these strategies are using identical name appearances on drug prescriptions and packages, using a visual cue to direct nurses' attention, and avoiding rushing nurses while they are concentrating.

APPLICATION

The findings aim to inspire recommendations for work system designs that will improve the visual search of look-alike drug names.

Visual differentiation and recognition memory of look-alike drug names: effects of disfluent format, text enhancement and exposure time

Three computer-based experiments were conducted to examine whether disfluent format, enhanced text, and increased exposure time improve the accuracy of visual differentiation and recognition memory of look-alike drug names. A three-way, repeated-measures look-alike drug name differentiation test assessed the visual differentiation accuracy of 30 nursing students (Experiment 1) and 15 nurses (Experiment 2). A two-way, repeated-measures recognition memory test examined the recognition memory accuracy of 15 nurses for look-alike drug names (Experiment 3). We found that making drug names disfluent did not significantly improve differentiation (Experiment 2) or memory accuracy (Experiment 3), but even impaired differentiation accuracy (Experiment 1). Enhanced text and longer exposure time significantly improved differentiation accuracy (Experiments 1 and 2). However, the enhanced text did not improve recognition memory (Experiment 3). We suggest that making look-alike drug names disfluent is not favourable. Enhanced text and longer exposure times are effective in supporting visual differentiation of look-alike drug names. Practitioner Summary: Confusion arising from look-alike drug names may compromise patient safety. Three experiments examined the effects of disfluent format, text enhancement and increased exposure time on visual and memory performances. Making drug names more difficult to read did not improve performance. Enhancing text design and increasing exposure (i.e. reading) time improved visual differentiation between medications, but did not improve the recognition of medications from memory. Abbreviations: SEEV: Salience-effort-expectancy-value; FDA: Food and Drug Administration; ANOVA: analysis of variance; SD: standard deviation, DF: disfluent format; TE: text enhancement; ET: exposure time.

Preventing dispensing errors by alerting for drug confusions in the pharmacy information system-A survey of users

Introduction

Drug confusion is thought to be the most common type of dispensing error. Several strategies can be implemented to reduce the risk of medication errors. One of these are alerts in the pharmacy information system.

Objective

To evaluate the experiences of pharmacists and pharmacy technicians with alerts for drug name and strength confusion.

Methods

In May 2017, a cross-sectional survey of pharmacists and pharmacy technicians was performed in community pharmacies in the Netherlands using an online questionnaire.

Results

Of the 269 respondents, 86% (n = 230) had noticed the alert for drug name confusion, and 26% (n = 67) for drug strength confusion. Of those 230, 9% (n = 20) had experienced that the alert had prevented dispensing the wrong drug. For drug strength confusion, this proportion was 12% (n = 8). Respondents preferred to have an alert for drug name and strength confusion in the pharmacy information system. ‘Alert fatigue’ was an important issue, so alerts should only be introduced for frequent confusions or confusions with serious consequences.

Conclusion

Pharmacists and pharmacy technicians were positive about having alerts for drug confusions in their pharmacy information system and experienced that alerts contributed to the prevention of dispensing errors. To prevent alert fatigue, it was considered important not to include all possible confusions as a new alert: the potential contribution to the prevention of drug confusion should be weighed against the risk of alert fatigue.

A systematic literature review on strategies to avoid look-alike errors of labels

PURPOSE

Unclear labeling has been recognized as an important cause of look-alike medication errors. The aim of this literature review is to systematically evaluate the current evidence on strategies to minimize medication errors due to look-alike labels.

METHODS

A literature search of PubMed and EMBASE for all available years was performed independently by two reviewers. Original studies assessing strategies to minimize medication errors due to look-alike labels focusing on readability of labels by health professionals or consumers were included. Data were analyzed descriptively due to the variability of study methods.

RESULTS

Sixteen studies were included. Thirteen studies were performed in a laboratory and three in a healthcare setting. Eleven studies evaluated Tall Man lettering, i.e., capitalizing parts of the drug name, two color-coding, and three studies other strategies. In six studies, lower error rates were found for the Tall Man letter strategy; one showed significantly higher error rates. Effects of Tall Man lettering on response time were more varied. A study in the hospital setting did not show an effect on the potential look-alike sound-alike error rate by introducing Tall Man lettering. Color-coding had no effect on the prevention of syringe-swaps in one study.

CONCLUSIONS

Studies performed in laboratory settings showed that Tall Man lettering contributed to a better readability of medication labels. Only few studies evaluated other strategies such as color-coding. More evidence, especially from real-life setting is needed to support safe labeling strategies.

Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years

BACKGROUND

Despite the widespread implementation of Tall Man lettering, little evidence exists regarding whether this technique has reduced drug errors due to look-alike sound-alike (LA-SA) drug names. This study evaluated rates of potential LA-SA drug errors in the drug management process through to the point of dispensing before and after implementation of Tall Man lettering in 2007.

METHODS

We used detailed pharmacy data for paediatric inpatients (<21 years old) from 42 children's hospitals in 2004-2012. After prespecifying a set of 8 potential LA-SA drug error patterns we searched within each hospitalisation for the occurrence of one of these patterns for a total of 12 LA-SA drug pairs deemed highly relevant to paediatric inpatients. To assess for potential change of error rates before and after Tall Man lettering implementation, we performed segmented regression analyses for each of 11 LA-SA drug pairs (because 1 pair had no detected potential errors) and for the overall total errors of all 11 LA-SA drug pairs.

RESULTS

Among 1 676 700 hospitalisations, no statistically significant change was detected for either the intercept or the slope of LA-SA error rate for each of the 11 drug pairs or for the combined error rate. In a sensitivity analysis of the moving average of the potential error rate over the entire study period, no downward trend in potential LA-SA drug error rates was evident over any time period 2004 onwards.

CONCLUSIONS

Implementation of Tall Man lettering in 2007 was not associated with a reduction in the potential LA-SA error rate. Whether Tall Man lettering is effective in clinical practice warrants further study.