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Kavanagh ON, Lowe R, Aronson JK. Errors associated with co-names of medicines: The nomenclature of combination medicinal products. Br J Clin Pharmacol 2024. [PMID: 39257096 DOI: 10.1111/bcp.16222] [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: 05/16/2024] [Revised: 07/02/2024] [Accepted: 08/06/2024] [Indexed: 09/12/2024] Open
Abstract
In comparison to the efforts required to bring a new drug or formulation to the clinic, bestowing a name on a medicine is relatively simple. However, if the name we choose causes confusion-by making its contents ambiguous or if it is too alike another drug-it can precipitate clinical errors. This prompted the World Health Organization to set up the International Nonproprietary Naming Committee in the 1970s to select unambiguous names for drugs. Unfortunately, multidrug products-which are becoming increasingly popular-do not fall under the remit of conventional International Non-proprietary Nomenclature. We have identified 26 combination formulations that have been historically named with the co-drug format in the United Kingdom. Most of them have also been prescribed in the United Kingdom in the past year, and although several of them are not prescribed very often, 11 were prescribed more than 2000 times. In this paper, we have explored the literature to identify prescribing errors with co-drug products and found several idiosyncrasies that have caused drug errors in the past. We advocate for a standard nomenclature (state the international nonproprietary name [INN] of each component followed by dose information in the x + y format) for these products on the box and in prescribing resources. We hope that this will enhance clarity and safety during prescribing and administration, particularly for high-volume drugs like paracetamol + codeine (co-codamol), amoxicillin + clavulanic acid (co-amoxiclav) and trimethoprim + sulfamethoxazole (co-trimoxazole).
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Affiliation(s)
- Oisín N Kavanagh
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK
| | - Robert Lowe
- Pharmacy Department, Hellesdon Hospital, Norwich, 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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Hu J, Chen Q, Lu D, He J. The impact of clock timing on VDT visual search performance under time constraint. Front Psychol 2024; 15:1369920. [PMID: 39077213 PMCID: PMC11284105 DOI: 10.3389/fpsyg.2024.1369920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 07/01/2024] [Indexed: 07/31/2024] Open
Abstract
Introduction Conducting Visual Display Terminal (VDT) visual search tasks under time constraint has broad applications in fields such as security checks, medical diagnostics, and rescue operations. While excessive time pressure can impair performance, moderate time pressure can motivate individuals to complete tasks and increase productivity. Investigating the positive impact of time pressure on visual search tasks has become a crucial area of study. Clock timing plays a vital role in the visual interface, influencing the perception of time pressure and impacting visual search performance. However, existing research has paid little attention to the induction of time pressure and the impact of clock timing in VDT visual interfaces on visual search performance. Hence, the objective of this study is to investigate the impact of clock timing on VDT visual search performance under time constraint. Methods The content of the experimental tasks was determined through a pilot experiment. The formal experiment was conducted in two phases over six sessions. Participants were tasked with locating the letter "E" embedded within the distractor letter "F," displayed with a clock area above the interface. The first phase of experiments included conditions of no clock, 4-min clock timing, and 4-min countdown clock timing. In the second phase of the experiment, the clock display method was a countdown clock, with three experiments conducted featuring long time, medium time, and short time. Search speed and accuracy were used as primary performance evaluation metrics to examine the impact of clock timing methods and duration on visual search performance. Twenty-one undergraduate students participated in the formal experiment. Results In the first phase of experiments, participants demonstrated significantly faster reaction times (RTs) in tasks where a clock display was present compared to tasks without (ANOVA, F(2, 60) = 4.588, P = 0.014). However, there were no significant differences in accuracy rates across different timing conditions (ANOVA, F(2, 60) = 0.146, P = 0.865), and no significant correlation between RTs and accuracy was found (Kendall's R = 0.11, P = 0.914). During the second phase, RTs decreased significantly as time constraints became more stringent (ANOVA, F(2, 60) = 7.564, P < 0.05). Conversely, accuracy rates decreased significantly under shorter time constraints (ANOVA, F(2, 60) = 4.315, P < 0.05), with a negative correlation observed between RTs and accuracy (Kendall's R = 0.220, P < 0.01). Discussion Compared to conditions without clock displays, having clock displays significantly improved the speed of the visual search task, although the difference in accuracy was not statistically significant. In the context of shorter clock countdown limits, Shorter timing constraints resulted in faster search speeds but also led to reduced accuracy and increased fatigue. Overall, a correlation exists between search speed and accuracy in visual tasks, where higher speed often correlates with lower accuracy. These findings provide valuable insights into clock timing design for visual search interfaces under time pressure.
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Affiliation(s)
- Jiabin Hu
- School of Art and Design, North China Institute of Science and Technology, Langfang, Hebei, China
| | - Qun Chen
- School of Art and Design, North China Institute of Science and Technology, Langfang, Hebei, China
| | - Danqiong Lu
- School of Art and Design, North China Institute of Science and Technology, Langfang, Hebei, China
| | - Jingkang He
- School of Electronics and Information Engineering, North China Institute of Science and Technology, Langfang, Hebei, China
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Im C, Song S, Kim K. The associations of psychological burnout and time factors on medication errors in rotating shift nurses in Korea: A cross sectional descriptive study. Nurs Open 2023. [PMID: 37115503 DOI: 10.1002/nop2.1794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 03/16/2023] [Accepted: 04/16/2023] [Indexed: 04/29/2023] Open
Abstract
AIM To describe the associations of psychological burnout and time factors on hospital nurses' medication errors. DESIGN A cross-sectional survey design was used. METHODS A structured questionnaire pertaining to psychological burnout, time factors and medication error was administered to 200 bedside nurses working at two tertiary university hospitals in Korea. The associations between the psychological burnout, time factor and medication error were analysed with the zero-inflated negative binomial regression for over-dispersed and over-abundant zeros count data. RESULTS Higher psychological burnout, shorter meal time during duty and longer weekly overtime were associated with an increased likelihood of medication error of nurses working in tertiary university hospitals. For medication safety, nurse managers should provide appropriate administrative support to nurses to cope with psychological burnout of nurses. Work time management should also be considered as human factors to satisfy the needs of nurses, such as securing meal times and maintaining a low level of weekly overtime.
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Affiliation(s)
- Cheongin Im
- Department of Nursing, College of Medicine, Inha University, Incheon City, South Korea
| | - Suyoung Song
- Department of Nursing, College of Medicine, Inha University, Incheon City, South Korea
| | - Kyoungja Kim
- Department of Nursing, College of Medicine, Inha University, Incheon City, South Korea
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Bitan Y, Nunnally ME. Shape Matters: A Neglected Feature of Medication Safety : Why Regulating the Shape of Medication Containers Can Improve Medication Safety. J Med Syst 2022; 47:6. [PMID: 36586046 DOI: 10.1007/s10916-022-01905-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 12/19/2022] [Indexed: 01/01/2023]
Abstract
This paper aims to highlight how to reduce medication errors through the implementation of human factors science to the design features of medication containers. Despite efforts to employ automation for increased safety and decreased workload, medication administration in hospital wards is still heavily dependent on human operators (pharmacists, nurses, physicians, etc.). Improving this multi-step process requires its being studied and designed as an interface in a complex socio-technical system. Human factors engineering, also known as ergonomics, involves designing socio-technical systems to improve overall system performance, and reduces the risk of system, and in particular, operator, failures. The incorporation of human factors principles into the design of the work environment and tools that are in use during medication administration could improve this process. During periods of high workload, the cognitive effort necessary to work through a very demanding process may overwhelm even expert operators. In such conditions, the entire system should facilitate the human operator's high level of performance. Regarding medications, clinicians should be provided with as many perceptual cues as possible to facilitate medication identification. Neglecting the shape of the container as one of the features that differentiates between classes of medications is a lost opportunity to use a helpful characteristic, and medication administration failures that happen in the absence of such intentional design arise from "designer error" rather than "user error". Guidelines that define a container's shape for each class of medication would compel pharmaceutical manufacturers to be compatible and would eliminate the confusion that arises when a hospital changes the supplier of a given medication.
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Affiliation(s)
- Yuval Bitan
- Department of Health Policy and Management, Ben-Gurion University of the Negev, Be'er Sheva, Israel.
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, Neurology, Surgery and Medicine, NYU Langone Health, New York, NY, USA
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Mitobe J, Higuchi T. Top-Down Processing of Drug Names Can Induce Errors in Discriminating Similar Pseudo-Drug Names by Nurses. HUMAN FACTORS 2022; 64:451-465. [PMID: 32830585 DOI: 10.1177/0018720820946607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND One factor that could cause medical errors is confusing medicines with similar names. A previous study showed that nurses who have knowledge about drugs faced difficulty in discriminating a drug name from similar pseudo-drug names. To avoid such errors, finger-pointing and calling (FPC) has been recommended in Japan. OBJECTIVES The present study had two aims. The first was to determine whether such difficulty was due to top-down processing, rather than bottom-up processing, being applied even for pseudo-names. The other was to investigate whether FPC affected error prevention for similar drug names. METHOD In two experiments, nurses and non-health care professionals performed a choice reaction time task for drug names and common words, with or without FPC. Error rate and reaction time were analyzed. RESULTS When drug names were used, nurses showed difficulty discriminating target names from distractors. Furthermore, the error prevention effect of FPC was marginally significant for drug names. However, nurses showed no significant differences when similar drug names were used. There was no significant difference regarding the error rate for words. CONCLUSIONS Nurses' knowledge of drug names activates top-down processing. As a result, the processing of drug names was not as accurate and quick as that for words for nurses, which caused difficulty in discriminating similar names. FPC may be applicable to reduce confusion errors, possibly by leading individuals to process drug names using bottom-up processing. APPLICATION The present study advances current knowledge about error tendencies with similar drug names and the effects of FPC on error prevention.
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Affiliation(s)
- Junko Mitobe
- 13270 Iryo Sosei University, Iwaki-shi, Fukushima, Japan
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Wang H, Tao D, Yan M. Effects of Text Enhancement on Reduction of Look-Alike Drug Name Confusion: A Systematic Review and Meta-analysis. Qual Manag Health Care 2021; 30:233-243. [PMID: 34326288 DOI: 10.1097/qmh.0000000000000303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Hailiang Wang
- School of Design, The Hong Kong Polytechnic University, Hong Kong, China (Dr Wang); Institute of Human Factors and Ergonomics, College of Mechatronics and Control Engineering, Shenzhen University, Shenzhen, China (Dr Tao); and School of Intelligent Systems Science and Engineering, Jinan University (Zhuhai Campus), Zhuhai, China (Dr Yan)
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Bryan R, Aronson JK, Williams AJ, Jordan S. A systematic literature review of LASA error interventions. Br J Clin Pharmacol 2020; 87:336-351. [PMID: 33197079 PMCID: PMC9328434 DOI: 10.1111/bcp.14644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Rachel Bryan
- College of Arts and Humanities, Swansea University, Swansea, UK
| | | | | | - Sue Jordan
- College of Arts and Humanities, Swansea University, Swansea, UK
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8
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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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9
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Liu K, Or CKL, Li SYW. Visual differentiation and recognition memory of look-alike drug names: effects of disfluent format, text enhancement and exposure time. ERGONOMICS 2019; 62:1289-1300. [PMID: 31173543 DOI: 10.1080/00140139.2019.1629637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 06/02/2019] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Kaifeng Liu
- Department of Industrial and Manufacturing Systems Engineering, The University of Hong Kong , Pokfulam , Hong Kong SAR , People's Republic of China
| | - Calvin K L Or
- Department of Industrial and Manufacturing Systems Engineering, The University of Hong Kong , Pokfulam , Hong Kong SAR , People's Republic of China
| | - Simon Y W Li
- Department of Applied Psychology, Lingnan University , Tuen Mun , Hong Kong SAR , People's Republic of China
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Abstract
OBJECTIVE Several factors contribute to medication errors in clinical practice settings, including the design of medication labels. The objective of this study was to quantify the impact of label design on medication safety in a realistic, high-stress clinical situation. METHODS Ninety-six anesthesia trainee participants were randomly assigned to either the redesigned or the current label condition. Participants were blinded to the study's focus on medication label design and their assigned label condition. Each participant was the sole anesthesia provider in a simulated operating room scenario involving an unexpected vascular injury. The surgeon asked the participant to administer hetastarch to the simulated patient because of hemodynamic instability. The fluid drawer of the anesthesia cart contained three 500-ml intravenous bags of hetastarch and one 500-ml intravenous bag of lidocaine. We hypothesized that redesigned labels would help participants correctly select hetastarch from the cart. If the participants incorrectly selected lidocaine from the cart, we hypothesized that the redesigned labels would help participants detect the lidocaine before administration. RESULTS The percentage of participants who correctly selected hetastarch from the cart was significantly higher for the redesigned labels than the current labels (63% versus 40%; odds ratio, 2.61 [95% confidence interval, 1.1-6.1]; P = 0.03). Of the participants who incorrectly selected lidocaine from the cart, the percentage who detected the lidocaine before administration did not differ by label condition. CONCLUSIONS The redesigned labels helped participants correctly select hetastarch from the cart, thus preventing some potentially catastrophic medication errors from reaching the simulated patient.
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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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Larmené-Beld KHM, Alting EK, Taxis K. A systematic literature review on strategies to avoid look-alike errors of labels. Eur J Clin Pharmacol 2018; 74:985-993. [PMID: 29754215 PMCID: PMC6061459 DOI: 10.1007/s00228-018-2471-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/25/2018] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Karin H M Larmené-Beld
- Department of Clinical Pharmacy, Isala Hospital, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
- Faculty of Mathematics and Natural Sciences, PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands.
| | - E Kim Alting
- Faculty of Mathematics and Natural Sciences, PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Katja Taxis
- Faculty of Mathematics and Natural Sciences, PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
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Integrating Data From the UK National Reporting and Learning System With Work Domain Analysis to Understand Patient Safety Incidents in Community Pharmacy. J Patient Saf 2017; 13:6-13. [PMID: 24583956 DOI: 10.1097/pts.0000000000000090] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To explore the combined use of a critical incident database and work domain analysis to understand patient safety issues in a health-care setting. METHOD A retrospective review was conducted of incidents reported to the UK National Reporting and Learning System (NRLS) that involved community pharmacy between April 2005 and August 2010. A work domain analysis of community pharmacy was constructed using observational data from 5 community pharmacies, technical documentation, and a focus group with 6 pharmacists. Reports from the NRLS were mapped onto the model generated by the work domain analysis. RESULTS Approximately 14,709 incident reports meeting the selection criteria were retrieved from the NRLS. Descriptive statistical analysis of these reports found that almost all of the incidents involved medication and that the most frequently occurring error types were dose/strength errors, incorrect medication, and incorrect formulation. The work domain analysis identified 4 overall purposes for community pharmacy: business viability, health promotion and clinical services, provision of medication, and use of medication. These purposes were served by lower-order characteristics of the work system (such as the functions, processes and objects). The tasks most frequently implicated in the incident reports were those involving medication storage, assembly, or patient medication records. CONCLUSIONS Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task.
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Lambert BL, Schroeder SR, Galanter WL. Does Tall Man lettering prevent drug name confusion errors? Incomplete and conflicting evidence suggest need for definitive study. BMJ Qual Saf 2015; 25:213-7. [PMID: 26700541 DOI: 10.1136/bmjqs-2015-004929] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Bruce L Lambert
- Department of Communication Studies, Center for Communication and Health, Northwestern University, Chicago, Illinois, USA
| | - Scott R Schroeder
- Center for Communication and Health, Northwestern University, Chicago, Illinois, USA
| | - William L Galanter
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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15
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Zhong W, Feinstein JA, Patel NS, Dai D, Feudtner C. Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years. BMJ Qual Saf 2015; 25:233-40. [PMID: 26534995 DOI: 10.1136/bmjqs-2015-004562] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/09/2015] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Wenjun Zhong
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James A Feinstein
- Division of General Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Neil S Patel
- Department of Pharmacy Services, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Dingwei Dai
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chirs Feudtner
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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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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17
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Oldland AR, Golightly LK, May SK, Barber GR, Stolpman NM. Electronic inventory systems and barcode technology: impact on pharmacy technical accuracy and error liability. Hosp Pharm 2015. [PMID: 25684799 DOI: 10.1310/hjp5001-034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To measure the effects associated with sequential implementation of electronic medication storage and inventory systems and product verification devices on pharmacy technical accuracy and rates of potential medication dispensing errors in an academic medical center. METHODS During four 28-day periods of observation, pharmacists recorded all technical errors identified at the final visual check of pharmaceuticals prior to dispensing. Technical filling errors involving deviations from order-specific selection of product, dosage form, strength, or quantity were documented when dispensing medications using (a) a conventional unit dose (UD) drug distribution system, (b) an electronic storage and inventory system utilizing automated dispensing cabinets (ADCs) within the pharmacy, (c) ADCs combined with barcode (BC) verification, and (d) ADCs and BC verification utilized with changes in product labeling and individualized personnel training in systems application. RESULTS Using a conventional UD system, the overall incidence of technical error was 0.157% (24/15,271). Following implementation of ADCs, the comparative overall incidence of technical error was 0.135% (10/7,379; P = .841). Following implementation of BC scanning, the comparative overall incidence of technical error was 0.137% (27/19,708; P = .729). Subsequent changes in product labeling and intensified staff training in the use of BC systems was associated with a decrease in the rate of technical error to 0.050% (13/26,200; P = .002). CONCLUSIONS Pharmacy ADCs and BC systems provide complementary effects that improve technical accuracy and reduce the incidence of potential medication dispensing errors if this technology is used with comprehensive personnel training.
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Affiliation(s)
- Alan R Oldland
- University of Colorado Hospital , Aurora, Colorado ; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences , Aurora, Colorado
| | - Larry K Golightly
- University of Colorado Hospital , Aurora, Colorado ; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences , Aurora, Colorado ; University of Colorado Health Sciences Library/Center for Drug Information, Education and Evaluation , Aurora, Colorado
| | - Sondra K May
- University of Colorado Hospital , Aurora, Colorado ; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences , Aurora, Colorado
| | - Gerard R Barber
- University of Colorado Hospital , Aurora, Colorado ; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences , Aurora, Colorado
| | - Nancy M Stolpman
- University of Colorado Hospital , Aurora, Colorado ; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences , Aurora, Colorado
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18
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Oldland A, Golightly L, May S, Barber G, Stolpman N. Electronic Inventory Systems and Barcode Technology: Impact on Pharmacy Technical Accuracy and Error Liability. Hosp Pharm 2015. [DOI: 10.1310/hpj5001-034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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19
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Oldland AR, Golightly LK, May SK, Barber GR, Stolpman NM. Electronic Inventory Systems and Barcode Technology: Impact on Pharmacy Technical Accuracy and Error Liability. Hosp Pharm 2015; 50:34-41. [DOI: 10.1310/hpj5001-34] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To measure the effects associated with sequential implementation of electronic medication storage and inventory systems and product verification devices on pharmacy technical accuracy and rates of potential medication dispensing errors in an academic medical center. Methods During four 28-day periods of observation, pharmacists recorded all technical errors identified at the final visual check of pharmaceuticals prior to dispensing. Technical filling errors involving deviations from order-specific selection of product, dosage form, strength, or quantity were documented when dispensing medications using (a) a conventional unit dose (UD) drug distribution system, (b) an electronic storage and inventory system utilizing automated dispensing cabinets (ADCs) within the pharmacy, (c) ADCs combined with barcode (BC) verification, and (d) ADCs and BC verification utilized with changes in product labeling and individualized personnel training in systems application. Results Using a conventional UD system, the overall incidence of technical error was 0.157% (24/15,271). Following implementation of ADCs, the comparative overall incidence of technical error was 0.135% (10/7,379; P = .841). Following implementation of BC scanning, the comparative overall incidence of technical error was 0.137% (27/19,708; P = .729). Subsequent changes in product labeling and intensified staff training in the use of BC systems was associated with a decrease in the rate of technical error to 0.050% (13/26,200; P = .002). Conclusions Pharmacy ADCs and BC systems provide complementary effects that improve technical accuracy and reduce the incidence of potential medication dispensing errors if this technology is used with comprehensive personnel training.
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Affiliation(s)
- Alan R. Oldland
- University of Colorado Hospital, Aurora, Colorado
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Larry K. Golightly
- University of Colorado Hospital, Aurora, Colorado
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
- University of Colorado Health Sciences Library/Center for Drug Information, Education and Evaluation, Aurora, Colorado
| | - Sondra K. May
- University of Colorado Hospital, Aurora, Colorado
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Gerard R. Barber
- University of Colorado Hospital, Aurora, Colorado
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Nancy M. Stolpman
- University of Colorado Hospital, Aurora, Colorado
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
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Sarfati L, Ranchon F, Vantard N, Schwiertz V, Gauthier N, He S, Kiouris E, Gourc-Berthod C, Guédat MG, Alloux C, Gustin MP, You B, Trillet-Lenoir V, Freyer G, Rioufol C. SIMMEON-Prep study: SIMulation of Medication Errors in ONcology: prevention of antineoplastic preparation errors. J Clin Pharm Ther 2014; 40:55-62. [DOI: 10.1111/jcpt.12225] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 09/24/2014] [Indexed: 11/29/2022]
Affiliation(s)
- L. Sarfati
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
| | - F. Ranchon
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
- Université Lyon 1, EMR UCBL/HCL 3738; Lyon France
| | - N. Vantard
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
| | - V. Schwiertz
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
| | - N. Gauthier
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
| | - S. He
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
| | - E. Kiouris
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
| | - C. Gourc-Berthod
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
| | - M. G. Guédat
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
| | - C. Alloux
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
| | - M.-P. Gustin
- Département de santé publique; Faculté de Pharmacie; Université Lyon 1; Lyon France
- Hôpital Nord-Ouest Villefranche-sur-Saône; Lyon France
- Hospices Civils de Lyon; Service de Biostatistique; Lyon France
| | - B. You
- Université Lyon 1, EMR UCBL/HCL 3738; Lyon France
- Medical Oncology Department; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Lyon France
| | - V. Trillet-Lenoir
- Université Lyon 1, EMR UCBL/HCL 3738; Lyon France
- Medical Oncology Department; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Lyon France
| | - G. Freyer
- Université Lyon 1, EMR UCBL/HCL 3738; Lyon France
- Medical Oncology Department; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Lyon France
| | - C. Rioufol
- Clinical Oncology Pharmacy Unit; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre Bénite France
- Université Lyon 1, EMR UCBL/HCL 3738; Lyon France
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21
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Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo Clin Proc 2014; 89:1116-25. [PMID: 24981217 DOI: 10.1016/j.mayocp.2014.05.007] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 05/12/2014] [Accepted: 05/16/2014] [Indexed: 11/28/2022]
Abstract
Medication error is an important cause of patient morbidity and mortality, yet it can be a confusing and underappreciated concept. This article provides a review for practicing physicians that focuses on medication error (1) terminology and definitions, (2) incidence, (3) risk factors, (4) avoidance strategies, and (5) disclosure and legal consequences. A medication error is any error that occurs at any point in the medication use process. It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths. Medication factors (eg, similar sounding names, low therapeutic index), patient factors (eg, poor renal or hepatic function, impaired cognition, polypharmacy), and health care professional factors (eg, use of abbreviations in prescriptions and other communications, cognitive biases) can precipitate medication errors. Consequences faced by physicians after medication errors can include loss of patient trust, civil actions, criminal charges, and medical board discipline. Methods to prevent medication errors from occurring (eg, use of information technology, better drug labeling, and medication reconciliation) have been used with varying success. When an error is discovered, patients expect disclosure that is timely, given in person, and accompanied with an apology and communication of efforts to prevent future errors. Learning more about medication errors may enhance health care professionals' ability to provide safe care to their patients.
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Affiliation(s)
- Christopher M Wittich
- Department of Internal Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
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22
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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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A Comparison of the Effects of Different Typographical Methods on the Recognizability of Printed Drug Names. Drug Saf 2014; 37:351-9. [DOI: 10.1007/s40264-014-0156-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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