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: 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 Error producing conditions 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 Dose, strength(s), dose form, packaging 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 Drug product ERROR The medical care “vortex”

ERRORS! Stress Culture New / Changed Product Or Process Suffixes Computers Marketing Combo product Suffixes Abbreviations Brand names Stress Doses Legibility Team Nomenclature Dose Regimens Patient Labels Care Setting Care Processes Communications New / Changed Product Or Process Fatigue Dose forms Routes Culture Knowledge Work condition Symbols Indication Language Task Generic names Human factors UBC Storage Packaging Purchasing ERRORS! Preparation

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: Just a matter of time…… 0.5mg, 1mg, 2mg, 3mg tablets XR

Legibility and drug names Unasyn or Vancomycin? Protonix or Protamine? Capoten or Cozaar?

Technology-drug product interface: Levophed for Lopressor

Why dose, route, frequency and indication are important: Error detected because dose was different Tricor for Tracleer Proscar in a female?? Error NOT detected because dose was the same

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.