# Presentation: 739159

## Look-Alike and Sound-AlikeMedicationsPractitioner Perspectives

- Timothy Lesar, Pharm.D.
- Director of Pharmacy
- Albany Medical Center
- Albany, NY

## Practitioner perspectives 

- Evidence base for comments
- Drug product – medical care system interactions and risk for errors
- Select examples
- Implications for risk reduction
- Implications for safety enhancements

## Evidence base for comments

- Systematic error detection, assessment, categorization and recording at AMC (since 1987) (> 32,000 prescribing errors)
- Nature of errors and contributors identified
- > 20% related to drug names and nomenclature
- Lesar et al, JAMA 1990;263:2329-34
- Lesar, Ann Intern Med 1992;117:537-8
- Lesar et al, Arch Intern Med 1997;157:1569-76
- Lesar et al, JAMA 1997;27:312-7
- Lesar, Arch Pediatr Adolesc Med 1998;152:340-4
- Purdy et al, Ann Pharmacother 2000;833-8
- Lesar, J Gen Intern Med 2002;17:579-87
- Lesar, Ann Pharmacother 2002;36:1833-9

## A GROWING PROBLEM:

- _A GROWING PROBLEM:_
- Number of dosage form related errors at AMC from 1996 to 2000  (> 75%  related to nomenclature)

## Emotional base for comments

**Drug names, nomenclature and packaging:**
- Often have a clear potential for error
- Commonly cause or contribute to patient harm.
- Cause or contribute to _**2 or more**_ significant medication errors _**every day**_ at AMC
*Perception* that safety is not always primary consideration in product naming.
- Simple product changes will reduce risk for error and enhance overall safety!

## Conceptual Framework

- Drug product inserted into complex care environment.
- Drug product interacts with care environment and care processes in identifiable (often surprising) and predictable fashion.
- These interactions will be determined by specific product characteristics and specific care processes
- Errors occur in predictable ways!
- Allows risk assessment
- Allows risk reduction
- Allows error prevention

## Conceptual Framework

**Risk for error and ADE**
- Error producing conditions
- Likelihood of error occurring
- Environment and processes of care
- Drug(s) involved
- Patient characteristic(s)
- Nature and type of error

## Conceptual Framework

**Any or all characteristics of a drug product can increase or decrease risk, and MUST be considered in risk assessment:**
- Generic name, brand name
- Dose, strength(s), dose form, packaging
- Route, frequency, instructions
- Storage requirements
- Indications, patient population
- Likely care environment
- Other

## Conceptual Framework

- The medical care “vortex”

- Drug product

**ERROR**

## ERRORS!

- Stress

- Care Processes

- Brand names

- Dose forms

- Generic names

- Doses

- Routes

- Communications

- Labels

**Symbols**

**Abbreviations**

- Legibility

- Human factors

- Storage

- UBC

**Packaging**

- Computers

- Culture

**Marketing**

- Work
- condition

- Fatigue

- Language

- Suffixes

- Combo
- product

- Patient

- Indication

- Care
- Setting

- Preparation

- Purchasing

**New /**
**Changed Product**
**Or**
**Process**

- Task

- Team

- Nomenclature

- Dose
- Regimens

- Knowledge

**ERRORS!**

## Selected Examples

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

## Predictable problems:Insulin brand names

- Humulin “Log” ordered instead of Humulin-L (Lente).
- Nurse thought Humalog” was to be given.

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

## Dosage form names: OxyContin and MSContin

- Dosage form names: OxyContin and MSContin

## Dosage form names:Just a matter of time......

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

**XR**

## Legibility and drug names

- Capoten or Cozaar?

- Protonix or Protamine?

- Unasyn or Vancomycin?

## Technology-drug product interface:Levophed for Lopressor

## Why dose, route, frequency and indication  are important: 

- Tricor for Tracleer

- Error detected because dose was different

- Error NOT detected because dose was the same

- Proscar in a female??

## Practitioner perspectives Implications for risk reduction and safety enhancements

- Predictable nature of errors allows risk assessment and reduction.
- Predictable nature of errors allows product design which can ***enhance*** safety.
- All drug product characteristics must be considered in risk assessment and prevention.
- Care environment and processes must be considered in risk assessment and prevention.

## Practitioners perspective  Summary

- Drug names, labels and packaging are major contributors to medication errors
- Risk for error is determined by both drug product characteristics and the care system processes.
- Risk assessment must include multiple drug characteristics (not just names)
- Risk of error within care system often readily apparent
- The  predictable nature of errors provides opportunity for  product naming and design which reduces risk and ***enhances*** safety.