How to prevent eye medication errors

Severe corneal burn due to the accidental application of salicylic acid packed in a plastic dropper bottle

Eye burns due to the accidental application of pharmacological or nonpharmacological substances packaged in plastic dropper bottles have been described for more than three decades and continue to occur. These burns can cause potentially serious corneal injuries. We report the case of a patient who mistakenly applied salicylic acid to the right eye after confusing it with an eye lubricant, which caused him a severe corneal burn. Fortunately, after aggressive medical and surgical management (including oxygen therapy and amniotic membrane grafting), the visual results were good. We suggest conducting educational campaigns and taking legislative measures in our country to avoid packaging corrosive substances in this type of dropper bottle to reduce the risk of accidental burns.

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

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.

The influence of tall man lettering on drug name confusion: a laboratory-based investigation in the UK using younger and older adults and healthcare practitioners

BACKGROUND

Medication errors commonly involve confusion between drugs with similar names. One possible method of reducing error is to emphasize differences between the names using 'Tall Man' (uppercase) letters (e.g. cefTAZidime vs cefUROxime). Previous studies investigating this issue have been conducted mainly on university students, and results have been mixed.

OBJECTIVE

To investigate the influence of Tall Man lettering on drug name confusion in other key participant groups.

STUDY DESIGN

Two separate experiments were conducted. In Experiment 1 (conducted at the University of Glasgow, Scotland, between January 2008 and May 2008), younger and older adults performed a same/different judgement task. In Experiment 2 (conducted at various sites in England between December 2008 and February 2009), healthcare practitioners performed a task based on electronic prescribing.

RESULTS

In Experiment 1, both younger and older adults made fewer name confusion errors when names contained Tall Man letters. Response times suggested that Tall Man lettering drew participants' attention to those letters, but that readers did not solely rely on these letters in making their response. In Experiment 2, healthcare practitioners made fewer name confusion errors when the names contained Tall Man letters.

CONCLUSIONS

Overall, results showed that Tall Man lettering reduced drug name confusion errors in a series of laboratory-based tasks, in both younger and older adults, and healthcare practitioners. Thus, the current findings offer some support for the use of Tall Man letters as a possible systems change that could be made by both pharmacies and manufacturers in an effort to reduce error caused by drug name confusion.

Using nurses and office staff to report prescribing errors in primary care

OBJECTIVE

To implement a prescribing-error reporting system in primary care offices and analyze the reports.

DESIGN

Descriptive analysis of a voluntary prescribing-error-reporting system

SETTING

Seven primary care offices in Vermont, USA.

PARTICIPANTS

One hundred and three prescribers, managers, nurses and office staff.

INTERVENTION

Nurses and office staff were asked to report all communications with community pharmacists regarding prescription problems.

MAIN OUTCOME MEASURES

All reports were classified by severity category, setting, error mode, prescription domain and error-producing conditions.

RESULTS

All practices submitted reports, although reporting decreased by 3.6 reports per month (95% CI, -2.7 to -4.4, P<0.001, by linear regression analysis). Two hundred and sixteen reports were submitted. Nearly 90% (142/165) of errors were severity Category B (errors that did not reach the patient) according to the National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors. Nineteen errors reached the patient without causing harm (Category C); and 4 errors caused temporary harm requiring intervention (Category E). Errors involving strength were found in 30% of reports, including 23 prescriptions written for strengths not commercially available. Antidepressants, narcotics and antihypertensives were the most frequent drug classes reported. Participants completed an exit survey with a response rate of 84.5% (87/103). Nearly 90% (77/87) of respondents were willing to continue reporting after the study ended, however none of the participants currently submit reports.

CONCLUSIONS

Nurses and office staff are a valuable resource for reporting prescribing errors. However, without ongoing reminders, the reporting system is not sustainable.

Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example

AIMS

The nature and incidence of errors in prescribing and giving medicines have previously been estimated by trained observers, or by retrospective analysis of incidents in which patients have come to harm. We have examined prospectively in routine clinical practice the concentrations of intravenous infusions of a drug (acetylcysteine) which is given according to a complicated dosing schedule.

METHODS

We prospectively collected samples before and, where possible, after the infusion of acetylcysteine in 66 anonymous patients requiring treatment for acetaminophen (paracetamol) overdose in four centres in the United Kingdom. We measured the concentration in each infusion bag, and deduced from the weight of the patient the percentage of the anticipated dose that had actually been given.

RESULTS

The experimentally determined dose was within 10% of the anticipated dose in 68 of 184 individual bags (37%), and within 20% of the anticipated dose in 112 bags (61%). Doses in 17 bags were more than 50% from the anticipated doses. In three patients, values in all three bags appeared to be systematically wrong by 50% or more; in a further seven cases, individual bags differed by 50% or more from the anticipated value. The median difference between pre- and post-infusion samples was 0% [interquartile range -5.2% to +14.6%], but 9% showed a disparity of greater than +/- 50%.

CONCLUSIONS

Our data suggest that there is large random variation in administered dosage of intravenous infusions. Systematic calculation errors occur in about 5% [95% confidence interval 2, 8%] of cases, and major errors in drawing up in a further 3% [1, 7%], with inadequate mixing in 9% [4, 14%]. While we have no evidence that patients were adversely affected, and while the regime of administration of the drug studied (acetylcysteine) is complicated, these data suggest that the delivered dose often deviates from the intended dose, and that methods of quality control are needed.