Medication Errors Look-Alike/Sound-Alike Medications

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Presentation transcript:

Medication Errors Look-Alike/Sound-Alike Medications Krystle Barroga, Erin Chun, Michelle Popek, Kate Takahashi, Sonia Lipka Nursing 362 Leadership

Action Step: Plan What is a med error? Any error occurring in the medication process PLAN: is to reduce medication error (drugs that sound and look alike) 50 % by March 2016. In the US Medication errors harm 1.5 million people and kill several thousand each year Cost to the nation is 3.5 billion annually 2003 to 2006 25,530 such errors were reported 2004 to 2008 11.7% to 14.4% unauthorized wrong drug med errors attributed to look alike drugs

Key players Errors involving these problematic name pairs may occur when: a prescriber interchanges the two medications when writing an order when someone misinterprets a written order when a person taking a verbal order does not hear the order as intended when selecting a medication when entering an order into a computer system when obtaining medications from storage

Examples of look-sound alike drugs

Quality Improvement Tool MEDICATION MANAGEMENT 1. Medication Reconciliation programs 2. CPOE (computerized provider order entry) 3. Barcoding 4. Look Alike, Sound Alike 5. Medication Metrodome project

Root Cause Analysis Patient received risperidone instead of ropinirole No specific indication for medication Medication’s stored in order, alphabetically Medication’s sound and look alike High acuity, short staffed Nurse was busy and distracted Patient Safety Compromised

Root Cause Analysis

Action Step: DO w/ Recommendations Develop policy and procedures for taking verbal and telephone orders Avoid abbreviations of drug names. Provide or ask for generic and brand names Include prompts for nurses to specify indication for use. Do not store medications alphabetically by name, store out order or in alternate locations. Place “Look Alike, Sound Alike” auxiliary alerts on medication storage bins. Use TALL MAN lettering to emphasize the spelling of drug names in medication storage areas. Horowitz, A. C. (2014). Prescription for safety. Long-Term Living: For The Continuing Care Professional, 63(1), 29-30. Improving medication safety. (2012). Committee Opinion No. 531. American College of Obstetricians and Gynecologists. Obstet Gynecol 120:406–10. Look-alike, sound-alike drug names. (2001). Sentinel Event Alert / Joint Commission On Accreditation Of Healthcare Organizations, (19), 1-4.

ISMP, FDA, The Joint Commission use tall man letters Method used to reduce confusion between drugs with look-alike or sound-alike names. Emphasizes sections of drug name by using upper case letters

ACTION STEPS: CHECK AND ACT Bar chart and run chart Monitor frequency of medication errors per month. ACT Implement quality improvement team to collect data. Have updated “Use Caution, Avoid Confusion” chart available and visible to staff members Have updated drug books available on unit Incorporate monthly in-services Inform current drug confusion

References: Anderson, P., & Townsed, T. (2010). Medication errors: Dont let them happen to you. American Nurse Today, 23-27. Retrieved February 21, 2015, from http://www.americannursetoday.com/assets/0/434/436/440/6276/6334/6350/6356/8b8dac76-6061-4521-8b43-d0928ef8de07.pdf FREQUENTLY ASKED QUESTIONS (Faq). (n.d.). Retrieved February 10, 2015, from http://www.ismp.org/faq.asp Horowitz, A. C. (2014). Prescription for safety. Long-Term Living: For The Continuing Care Professional, 63(1), 29-30. http://www.ihi.org/Topics/PatientSafety/Pages/default.aspx http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/index.html Improving medication safety. (2012). Committee Opinion No. 531. American College of Obstetricians and Gynecologists. Obstet Gynecol 120:406–10. Kelly, W., Grissinger, M., & Phillips, M. (2010). Look Alike Drug Name Error. Patient Safety & Quality Healthcare. Retrieved February 21, 2015, from http://psqh.com/look-alike-drug-name-errors Kim, J., & Bates, D. W. (2013). Medication administration errors by nurses: adherence to guidelines. Journal Of Clinical Nursing, 22(3/4), 590-598. doi:10.1111/j.1365-2702.2012.04344.Look-alike, sound-alike drug names. (2001). Sentinel Event Alert / Joint Commission On Accreditation Of Healthcare Organizations, (19), 1-4. Institute For Safe Medication Practices. (n.d.). Retrieved February 9, 2015, from http://www.ismp.org/