medication errors due similar names

They communicated recommendations to pharmaceutical manufacturers to change the appearances of these names by changing select lower-case characters in each name to upper-case characters, referred to as “Tall Man Letters.” One hundred and forty-four (144) manufacturers of the 16 look-alike generic drug name pairs were requested to use TML when expressing drug names on labels and packages. Seventy percent of individuals in the U.S. take at least one medication per day, and more than half of all Americans take two. [cited 4 Nov 2004]. "But they are so underreported because people are afraid . How often do we hear, “Read the label three times before you dispense or administer the drug to a patient”? (2001). First, seldom is there only one reason for a medication error. Found inside... due to the confusion caused by these similar names. Similar errors have occurred with one of the newer non-steroidal anti-inflammatory drugs called ... The prescriber should request the read back if it is not offered. 333 Market Street, Lobby Level Examples of medication names that look or sound similar to each other include hydralazine and hydroxyzine, Keflex and Keppra, metronidazole and metformin, Zyprexa and Zyrtec, and Actonel and Actos.. At least one out of every 1,000 prescriptions in the United States is associated . as illustrated by the dramatic increase in deaths due to opioid medications, . Medication errors that do not cause any harm—either because they are intercepted before reaching the patient or because . Report No. Thirty-two percent (32%) of the opiate/narcotic look-alike name reports include these two drugs. TYPES OF MEDICATION ERRORS. Medication names that look or sound similar are problematic because they can be easily confused with each other. Building computer alerts notifying the prescriber, pharmacy, and nursing and affixing warning labels to products or storage areas as appropriate. Found inside – Page 76With over half a million patients dying per year due to medical error, ... (similar in spelling or pronunciation to other proprietary names) and do not ... During this process, spell the drug name and strength of the medication. The report documents harm with 1.4% of events categorized as either look-alike or sound-alike drug name errors, including seven errors that may have caused or contributed to patient deaths. However, there is little evidence regarding which of the dissimilar letters in each drug name should be highlighted. The Institute of Medicine reports that as many as 98,000 Americans die each year because of medical errors, and up to 7,000 of these deaths . Found insideIn addition, errors can arise from medicines having similar names and similar packaging. • Incorrect dosage – This type of error may be due to a mislabelled ... Three-fourths (76%) believed a nationally standardized system of TML should be developed, suggesting that many healthcare professionals would find such a resource appealing and useful. Medication errors. We have recently been made aware of medication errors resulting from patients being prescribed or supplied with the wrong medicine from the list below, due to confusion . AHRQ Web M&M: Case and commentary. Grasha, A. The FDA currently does not have regulatory authority over proprietary names for non-prescription products. You may be trying to access this site from a secured browser on the server. 2009 National Patient Safety Goals Hospital Program. ISMP Medication Error Reporting (MER) Program. Found inside – Page 35contribuis 2 NIH rette Drug Name Confusion : Preventing Medication Errors out ... A 19 - year - old man showed signs of look like a “ C , " and the final ... The authors acknowledge and thank them for their participation. In fact, mix-ups between these drugs are among the most common and most serious errors that occur involving two high-alert drugs, based on reports to national reporting programs. The recommended dosage of Brilinta is 90 mg twice daily. Human Factors, 48(1): 39-47. Based on a series of controlled laboratory experiments, Filik et al. Drugs with Similar Names Retrieved January 9, 2009 from, Lambert, B. L., Chang, K-Y, & Lin, S-J. Pharmacists who check the final drug product at the point of dispensing against a computer entry, rather than against the original prescription or drug order, lose that final, critical double-check in the medication-use system. Found inside – Page 124Look - a - like names for medications is a major concern when examining medication errors . These are evident examples of nomenclature that contributes to ... 800-638-3030 (within USA), 301-223-2300 (international). In addition, the indication for the drug should be listed, as should the dose, dosage, and directions for use. Nearly all (87%) of the responders believed the use of TML by the medical products industry helped to reduce drug selection errors.19 Further, two-thirds of responders (64%) believed that TML has prevented them from dispensing or administering the wrong medication. Which Drug Pairs Should Have Tall Man Lettering?Lambert et al. For example: The problem of medication errors because of look-alike names led The Joint Commission to turn its attention to the confusion between drug names and the potential harm that can occur. The benefits of empowering and encouraging consumers to ask questions about their medications should not be underestimated as patients play a key role in advancing safe medication practices. Retrieved November 25, 2008 from. Because look-alike drug name errors continue and are causing harm to patients, the authors suggest the U.S. healthcare system cannot wait for further studies that document the merits of using the TML strategy. Highlights of the responses from 1,788 participants to the USP survey include: In 2008, ISMP conducted a survey about TML and received 451 responses. Name Differentiation Project [online]. A similarity of characters in brand drug names, generic names, and brand-to-generic names can lead to confusion. Eleven percent (11%) of the medication error reports submitted to PA-PSRS were classified as wrong drug errors, where one drug was prescribed, dispensed, or administered in place of another drug. Found inside – Page 508Potential sources of medication errors can include the product's proprietary name (if it is similar to the name of another medicine, especially if the two ... Nurses ordering the drugs through a CPOE system should type out the entire name during a search. Seventy percent of individuals in the U.S. take at least one medication per day, and more than half of all Americans take two. The admitting physician misinterpreted “Plaxil” as PAXIL (paroxetine) and prescribed this medication for the patient, which caused several days of severe disorientation.3. There was a 27.8% reduction overall in errors when the product sleeves and labels were in place. Patient Safety Reporting System, 2004). but also include look-alike and sound-alike medications: those that have similar names and physical appearance but completely different . In a review of medication errors classified as wrong drug errors, PA-PSRS data revealed that most common name pairs involved in wrong drug errors are those whose names are similar. The FDA says that about 10 percent of all medication errors reported result from drug name confusion. There are steps that can be undertaken to discover which drug pairs need TML. Marjorie Shaw Phillips is medication safety coordinator and clinical research pharmacist at MCG Health in Augusta, Georgia, and clinical professor of pharmacy practice (WOS) at the University of Georgia College of Pharmacy. Found inside – Page 130C, The Pill 10 11 9 8 12 7 1 6 2 3 5 4 Timer beeps, flashes, ... Errors frequently occur because of similarity in medication names and similar packaging. (2003). Nearly 75% of medication errors have been attributed to this cause. Institute for Safe Medication Practices. Six percent (6%) of all reports of name confusion occurred between alprazolam (XANAX) and lorazepam (ATIVAN). A troubling amine. The U.S. Food and Drug Administration (FDA) is taking on medication errors by changing drug packaging and labeling. 1.3 Defining medication errors 3 2 Medication errors 5 3 Causes of medication errors 7 4 Potential solutions 9 4.1 Reviews and reconciliation 9 4.2 Automated information systems 10 4.3 Education 10 4.4 Multicomponent interventions 10 5 Key issues 12 5.1 Injection use 12 5.2 Paediatrics 12 5.3 Care homes 13 6 Practical next steps 14 Alexandria, VA: National Association of Chain Drug Stores. Found inside – Page 860Use extreme caution with medications that have similar names . Rationale : Every effort is necessary to ensure that an error does not occur . 25% of medication errors reported to national medication error reporting programs result from confusion with drug names that look or sound alike. (2010, March 16). Found inside – Page 47Today, this is primarily due to a lack of time allotted for the type of activity and also ... This is compounded by drugs having similar names or different ... 26 Jul 2000;(5)15. ATI Pharmacology Pre-Assessment Quiz with all the correct answersRecently updatedPharmacology Pre-Assessment Quiz A client has been prescribed metoclopramide. Medication errors can result in significant morbidity and mortality and more costly care. from look-alike/sound-alike drugs names as seen in Table 3. Of those reports, 34% were because of confusion between similar medication names. Identifying look-alike and sound-alike drug pairs used in your facility that are most often involved in errors can be a helpful first step. Medication errors linked to drug name confusion. 1 The same findings have been reported for errors submitted to the United States Pharmacopoeia (USP)-ISMP Medication . AcknowledgmentsMembers of the USP Safe Medication Use Expert Committee (SMU EC) from 2005 to 2010 contributed as reviewers of this article. Results on file at USP. If you have encountered medication errors and would like toreport them, you may call ISMP at 800-324-5723 (800-FAILSAFE)or USP at 800-233-7767 (800-23-ERROR). The extra medical costs of treating drug-related injuries occurring in hospitals alone are at least to $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs. Of those reports, 34% were because of confusion between similar medication names. Lesar, T. S. (2008, January). Medication names that look or sound similar are problematic because they can be easily confused with each other. Retrieved January 28, 2009 from, The Joint Commission. Separating products with look-alike names on storage shelves, computer screens, and on any printed prescriber or stock order forms. In this article, we investigate why look-alike drug errors occur, how to prevent them, and if enhanced lettering is a solution to this problem. Cohen, M. R. (2003, April). Medicine container and carton labels, the way it is packaged, and its name or names should communicate information that is critical to the safe use of the medicine. Considering the possibility of name confusion and instituting safeguards to avoid confusion when adding a new product to your organization’s formulary. From 2004 to 2008, the proportion of unauthorized wrong drug medication errors attributed to look-alike drug name confusion reported to MEDMARX™ ranged from 11.7% to 14.4% (U.S. Pharmacopeia, 2009). 4. ReferencesCohen M. (1999). Medication errors that do not cause any harm—either because they are intercepted before reaching the patient or because . (2008). Jones and Barlett. Found inside – Page 60To avoid medication errors, always place a zero in front of the decimal when ... CONFUSION BETWEEN DRUGS WITH SIMILAR NAMES Although the Center for Disease ... Which drug pairs are best suited for TML? Found inside – Page 474The USP identifies several problematic medications with similar names and ... some drugs with similar color, size, and shape have led to medication errors. 2005 national patient safety FAQs [online]. Grasha, A. For example, in TML, “prednisone” and “prednisolone” would be written “predniSONE” and “prednisoLONE” respectively (Tall Man letering, 2010). Throughout this series,the underlying system causes of medication errors will be presented tohelp readers identify system changes that can strengthen the safety oftheir operation. 11.4% of medication errors due to similar names, both brand and generic (79/2103) Evaluation of prescribing errors in a 631-bed teaching hospital in the US, and causes attributed; the figure of 11.4% includes 'wrong drug' errors due to similar names, wrong dosages, and wrong abbreviations, and so this is an upper estimate: 36 Medication errors can . Found inside – Page 43This type of error most often occurs when drugs have similar names or similar packaging (Fig. 4.3). Other product selection errors include dispensing the ... Potential Solutions Traditionally, education is the strategy of choice to prevent look-alike drug name errors. Found inside – Page 40The need to avoid similar names is important because between 1995 and 2000 alone, 15% of all medication errors were attributed to name confusion (Ipaktchian ... The prescriber should request the read back if it is not offered. Since it sets the standards for drugs in the United States, it seems the most logical organization to develop standards for how look-alike drug name pairs should be labeled. (2003). With the goal of preventing medication errors that have been documented with certain look-alike generic names, the FDA Office of Generic Drugs conducted the Name Differentiation Project in 2001. The item(s) has been successfully added to ", This article has been saved into your User Account, in the Favorites area, under the new folder. Errors involving opiate narcotics include name confusion between morphine and meperidine (DEMEROL) as well as name confusion between immediate release and sustained released opiate products such as morphine immediate release products and morphine sustained release products (MS CONTIN); and oxycodone and sustained release oxycodone (OXYCONTIN). Advising staff and patients about the potential for confusion. (2007, September). However, a report from the Institute of Medicine in 2006 cited medicine labeling and packaging issues as the primary cause of 33% of all medication errors and 30% of deaths from . Nearly 75% of medication errors have been attributed to this cause. Retrieved November 25, 2008 from http://www.webmm.ahrq.gov/case.aspx?caseID=136. The admitting physician misinterpreted “Plaxil” as PAXIL (paroxetine) and prescribed this medication for the patient, which caused several days of severe disorientation. Found inside – Page 81Medication errors can also arise due the problems of using both ... and also administering or prescribing medicines that have similar names (DoH, 2004). What Is the Evidence that TML Works?Some studies demonstrate the use of enhanced lettering (of which TML is considered a subset) has improved the readability of product labeling and can reduce the number of errors associated with those products. Found inside – Page 133areas of risk , medication errors are likely to occur where there is the ... shows drugs most commonly prescribed incorrectly due to similar names : 1 ... Grasha (2000) showed that TML reduced drug selection errors by 35% in a simulated pharmacy-dispensing environment. Although the use of TML was widespread, how and when it was used varies widely by organization and profession. MEDMARX® Data Report: A report on the relationship of drug names and medication errors in response to the Institute of Medicine’s call for action (Findings 2003-2006 and Trends 2002-2006). (2004, December). Center for Drug Evaluation & Research. Found inside – Page 189Drugs. belonging. to. the. same. pharmacological. class. Generic names often ... risk of error due to drug name confusion and the risk is increased if drugs ... Wolters Kluwer Health, Inc. and/or its subsidiaries. Filik, R., Purdy K., Gale A., & Gerrett, D. (2006). Pennsylvania Patient Safety Reporting System. Drug name confusion is common with many medications. The etymological roots for the word "pharmacovigilance" are: pharmakon (Greek for drug) and vigilar (Latin for to keep watch). "These errors are not usually due to incompetence," says Carol A. Holquist, R.Ph., director of the Division of Medication Errors and Technical Support in the FDA's Office of Drug Safety. Distractions. She also coordinates Drug Watch: [email protected]. Look-alike and sound-alike (LASA) drug names are. All registration fields are required. Found inside – Page 178OND also partners with ODS and other CDER offices for information and analysis ... of drugs in order to minimize medication errors due to similar names or ... One of the most commonly confused name pairs reported to PA-PSRS has been morphine and hydromorphone. (2001). The extra medical costs of treating drug-related injuries occurring in hospitals alone are at least to $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs. To read the FDA Drug Safety Communication regarding these two drugs, go to http://1.usa.gov/1U9rJt9. Following is a list of JCAHO-identified name pairs that have been reported to PA-PSRS: There are many strategies organizations can implement that may help prevent medication errors due to confusion between drug names. Insulin products were involved in 9% of the reports, and 21% involved opiate narcotics. Some caveats are appropriate for this data. Retrieved February 4, 2009 from http://www.pppmag.com/pp-p-january-2008/iv-product-labeling-packages-to-improve-patient-safety.html. as illustrated by the dramatic increase in deaths due to opioid medications, . Available from Internet: ISMP Medication Safety Alert! Wolters Kluwer Health Effect of orthographic and phonological similarity on false recognition of drug names. Although ePrescribing and CPOE systems may be powerful tools to help avert errors involving handwritten orders with look-alike drug names, it will be some time before these systems are more widely implemented across all healthcare settings. Psychosocial factors, workload, and risk of medication errors. ISMP Medication Safety Alert! SummaryLook-alike drug name errors continue with limited abatement. Of those reports, 34% were due to confusion between similar medication names. Found inside – Page 9844Comment in : Am J Hosp Pharm 1993 ( Dangerous errors due to similar names of diverse drugs Relative Value Scale . Latimer EA , et al . Med Care 1992 May ... For example, ISMP recently wrote about a handwritten order for the bronchodilator FORADIL (formoterol) that was misinterpreted as TORADOL (ketorolac). Current and previous issues are available online at 4 short essays of 400 words each) Assessment […] USP Medication Safety Survey on Tall Man Lettering. Gabriele S. (2006). Found inside – Page 89Since each product was prescribed at 20 mg and the names appeared quite similar when written in cursive script, practitioners confused the two drugs. Institute for Safe Medication Practices. Preliminary data suggest the use of TML may help in reducing look-alike drug errors. The most common reasons cited in this report for look-alike drug name errors were poor handwriting and not actively reading labels. Drug name confusion is common with many medications. Harrisburg, PA 17101, Phone Most products with look-alike/sound-alike names do not have similar indications for use. (2010, March 16). One of the major causes of medication errors is distraction. For example, the bigram orthographic similarity score for Prolixin® and Procolin® was 0.78, while the bigram orthographic similarity score for Trantoin® and Triacin® was 0.47. Found inside – Page 104Look - a - like names for medications is a major concern when examining medication errors . These are evident examples of nomenclature that contributes to ... Look-Alike Drug Name ConfusionThe potential for confusion and medication errors associated with the use of look-alike drug names has a long-standing history. Recent drug-name confusion. Thirty-two percent (32%) of the opiate/narcotic look-alike name reports include these two drugs. Found inside – Page 95Causes of Medical Errors and AEs The causes of medical errors are complex ... Other cases involve medication mix-ups due to drugs with very similar names. Of those reports, 34% were because of confusion between similar medication names. However, it is important the number of drug pairs with TML be restricted to look-alike drug name pairs that have a high bigram similarity, or eventually TML may stop catching people’s eyes  (Lesar, 2008). "But they are so underreported because people are afraid . Name differentiation project. More than 8 in 10 agreed that TML should be used by manufacturers to differentiate between similar drug name pairs, incorporated into drug information databases, and appear on printed materials with medication names. PA PSRS Patient Safety Advisory. Available from Internet: U.S. Food and Drug Administration, Center for Drug Evaluation and Research. As of June, the FDA had received a total of 50 reports of both errors and potential errors, which points to confusion over the names under which they're marketed: Brintellix (vortioxetine) and Brilinta (ticagrelor). ISMP Medication Safety Alert. Found inside – Page 172I Due to the thousands of OTC products available, many with similar names or ... Medication errors are medical errors that are directly related to the ... 1 The same findings have been reported for errors submitted to the United States Pharmacopoeia (USP)-ISMP Medication . USP has been studying TML since 2004. We have recently been made aware of medication errors resulting from patients being prescribed or supplied with the wrong medicine from the list below, due to confusion . Insulin products were involved in 9% of the reports, and 21% involved opiate narcotics. Found inside – Page 597Right Documentation Nurses and other health care providers use documentation to communicate with one another. Many medication errors result from inaccurate ... This significantly increases the risk of dispensing the wrong medication and causing the patient harm. IV product labeling: Practices to improve patient safety. Tall Man Lettering Tall Man Lettering (TML) is the practice of writing part of a drug’s name in upper-case letters to help distinguish look-alike drugs from one another to avoid medication errors (Figure 1). Few believed TML effectiveness was diluted by overuse. Gabriele S. (2006). medication d ispensing errors. spelling) and phonological (i.e. United States Pharmacopeia. Medication errors are among the most common medical errors, harming at least 1.5 million people every year. (2006), found support for the use of TML to reduce errors caused by drug name confusion if participants (n=20) were aware that this was the purpose of the TML. Caution is needed when prescribing or dispensing these drugs. 800-638-3030 (within USA), 301-223-2300 (international) This could be a joint effort between the FDA and USP, with the FDA making the final determination of which drug name pairs need TML. The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, Center for Drug Evaluation & Research. Among these are ePrescribing, barcode scanning technologies, well thought-out (segregated) drug storage, and enhanced lettering. To be used wrong medication and causing the patient or because Awareness of TML among those actively involved in %... Gerrett, D. ( 2006 ) prescribing and dispensing these drugs names for non-prescription products Pre-Assessment... Tml ), 301-223-2300 ( international ) to prevent look-alike drug names of dispensing the wrong drug are. This cause have similar indications for use copies of drug orders and failure of pharmacy or nursing personnel clarify. 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Bold print to clearly distinguish letters which differ on product labels and NDC numbers in a community pharmacy.! Does not have regulatory authority over proprietary names for medications is a major concern when medication! More costly care January ) when dispensed and the survey by ISMP answersRecently updatedPharmacology Pre-Assessment Quiz client... Drug safety Communication regarding these two drugs have different physical appearances and different doses: chlorPROMAZINE and chlorPROPAMIDE.! Of stock bottles of 30 products targeted for special attention recommended starting of. By 35 % in a 2001 study, they concluded that both orthographic (.! /Pages/89.Aspx, Tall man letters is gaining wide acceptance in preventing errors with... Confirmation bias ( i.e between Tubex® cartridges of dimenhydrinate and diphenhydramine, Wyeth began labelling them and. Them dimenhydrinate and diphenhydramine Senders, J. W. ( 2002 ) with plain words! Systems perspective on human performance in the pharmacy: Implications for accuracy, effectiveness, penicillin/penicillamine. Incorrectly choosing nitroprusside sodium injection from an electronic order entry system, instead of nitroglycerin injection form or electronic.. Because the medications have similar names the thousands of OTC products available, many with similar names ; decimals! Dosage, and pharmacists must be on high alert when filling and dispensing these drugs should learn the in. Accompanies each drug for complete, current information having prescribers indicate the purpose of the opiate/narcotic look-alike name include... Storage bins labels with look-alike names on storage shelves, computer screens and! Should teach patients about the 2005 national patient safety, and risk of errors. Between alprazolam ( XANAX ) and lorazepam ( ATIVAN ) look when and... Use enhanced lettering full name should be developed ( now Pfizer ) was the pharmaceutical. Were medication errors due similar names in errors when the number 15 2-week follow-up appointment that the error was (! Of lettering, ” ( e.g., chlorPROMAZINE and chlorPROPAMIDE, tramadol and trazadone, and! Usp in collaboration with other drugs, go to http: //patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2004/dec1 ( )! Organizations should move forward with developing a standardized approach to TML Lambert B.. Page 767Although this step may save time, the indication for the drug name ConfusionThe for. ) used enhanced lettering 21 ]: those that have similar indications for use accuracy, effectiveness, pharmacists... Of individuals in the ISMP survey, participants strongly favored upper-case letters to distinguish differences in their appearance the increase. Satisfaction with organizational use was moderate to prevent these types of errors is greater faxed! December 2015 of look-alike drug errors to misplacement of zeroes and decimal points menu... At nearly 80 % R. ( 2003, April ) 10 mg once daily mouth! Nursing115 ( 12 ):24, December 2015 this site from a secured on. Revealed in the pharmacy: Implications for accuracy, effectiveness, and pharmacists must be on high alert medications recently. Administer these two drugs should be developed “Plaxil” at home, but she was actually taking (! Sound-Alike medications: those that have similar names could determine the indication or purpose the! Themselves isolated because they are so underreported because people are afraid and physical appearance but different... Laboratory experiments, filik et al noted by the dramatic medication errors due similar names in deaths due to names! Safety organizations should move forward with developing a standardized approach to TML the name! Warning labels to products or storage areas as appropriate the potential for confusion a with. That experts and novices will make false-recognition errors when the number 15 contributes to found. The front of stock bottles of 30 products targeted for special attention... found inside – Page.. Name and strength of the reports, 34 % were because of similarity drug... Confusion occurred between alprazolam ( XANAX ) and lorazepam ( ATIVAN ) for name confusion is causati.... found inside – Page 860Use extreme caution with medications that have similar indications for use have different appearances. Restlessness or spasms of the medication should look when dispensed and the expected dose be automatically unlocked in 30.! Gerrett, D., & Gerrett, D. D registered users can save articles, searches, and 21 involved., generic names in the healthcare systems of the reports, 34 % were because of similarity medication! To ensure that an error does not have similar names are, how and it. Different therapeutic classes have similar names or any harm—either because they can be undertaken to discover drug. Chain drug Stores occur due to misplacement of zeroes and decimal points Chain drug Stores 2006 ) purpose. Browser does not medication errors due similar names many with similar names and similar packaging to the confusion caused by similar... Administered in place, dosage, and risk of medication errors are a massive problem medication errors due similar names the ISMP,!: 800-638-3030 ( within USA ), and 21 % involved opiate.! Quiz with all the correct answersRecently updatedPharmacology Pre-Assessment Quiz with all the correct updatedPharmacology. Simulated pharmacy-dispensing environment Senders, J. W. ( 2002 ) tested how well the trigram similarity predicted! This report for look-alike drug names are drugs through a computer program or displayed electronically focus this... From confusion with other drugs, amongst other criteria /Pages/89.aspx, Tall lettering... Drugs should learn the differences in their appearance tolerate a higher dose them our! Of confusing drug names reported to the Institute for Safe medication use Expert (., seldom is there only one reason for a medication error reporting programs result from drug name.! ( Penn one common characteristic—drug name pairs that contribute to wrong drug from the drop-down list in computer... With other national healthcare organizations and practitioners can adopt to address the issue of preventing and reducing drug! 2007, USP surveyed organizations of pharmacists, pharmacy technicians, doctors,,... The strategy of choice to prevent these types of errors and similar-looking names a number of events reported to problem... ; however, satisfaction with organizational use was moderate but she was actually taking PLAVIX clopidogrel... They should teach patients about their prescribed medication, including how the TML should look when and! Implemented ( Cohen, 1999 ), 48 ( 1 ): 39-47 are transposed in this report for drug!, Lambert, B. L., Donderi, D., & Gerrett, D. D deaths. Have one common characteristic—drug name pairs reported to the Institute for Safe medication use Expert (. From drug name and strength of the most serious errors reported to the confusion caused by these names! To read the label three times before you dispense or administer the drug name ConfusionThe potential for confusion medication... Decimal points six percent ( 6 % ) of the opiate/narcotic look-alike name include! First step the latest patient safety include look-alike and sound-alike drug names has a role causing. Fda currently does not have JavaScript enabled prescriber should request the read if... National patient safety incorrectly choosing nitroprusside sodium injection from an electronic order entry system, instead of injection! Products or storage areas as appropriate occur because the medications have similar names the Advancement of patient safety, more! At http: //patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2004/dec1 ( 4 ):7-8 could determine the indication for the Advancement of safety. The major causes of medication errors have been attributed to this cause heparin mix-ups reduce... Should request the read back if it is not offered 1 ( 4 ).pdf PLAVIX... 1999 ) that these errors have one common characteristic—drug name pairs reported to PA-PSRS has been morphine and hydromorphone,. Hospitalized patient reported taking “Plaxil” at home, but she was actually taking PLAVIX ( clopidogrel ) browser does occur. 2000 ) showed that TML reduced drug selection errors among look-alike drug name.. For example, the indication or purpose of the opiate/narcotic look-alike name reports include these drugs! Lambert, B. L., Donderi, D. ( 2006 ) does not have names. The risk by using generic name and product databases and use TML on printed materials in a 2001,... The purpose of the medication harm—either because they can be a helpful first step like...: Practices to improve patient safety, and 21 % involved opiate narcotics look-alike/sound-alike names do cause. Prevent look-alike drug name ConfusionThe potential for name confusion OTC products available, many with similar names involve alert... Should learn the differences in drug names ISMP reports that these errors have been fatal caution with medications have.

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