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

2. 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 ,530 such errors were reported
2004 to % to 14.4% unauthorized wrong drug med errors attributed to look alike drugs

3. 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

4. Examples of look-sound alike drugs

5. 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

6. 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

7. Root Cause Analysis

8. 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),
Improving medication safety. (2012). Committee Opinion No 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.

9. 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

10. 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

11. References:
Anderson, P., & Townsed, T. (2010). Medication errors: Dont let them happen to you. American Nurse Today, Retrieved February 21, 2015, from
FREQUENTLY ASKED QUESTIONS (Faq). (n.d.). Retrieved February 10, 2015, from
Horowitz, A. C. (2014). Prescription for safety. Long-Term Living: For The Continuing Care Professional, 63(1),
Improving medication safety. (2012). Committee Opinion No 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
Kim, J., & Bates, D. W. (2013). Medication administration errors by nurses: adherence to guidelines. Journal Of Clinical Nursing, 22(3/4), doi: /j 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