1. Look-Alike and Sound-Alike Medications Practitioner Perspectives
Timothy Lesar, Pharm.D.
Director of Pharmacy
Albany Medical Center
Albany, NY

2. 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

3. 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:
Lesar, Ann Intern Med 1992;117:537-8
Lesar et al, Arch Intern Med 1997;157:
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

4. A GROWING PROBLEM:
Number of dosage form related errors at AMC from 1996 to (> 75% related to nomenclature)

5. 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!

6. 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

7. 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

8. 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

9. Conceptual Framework
Drug product
ERROR
The medical care “vortex”

10. 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

11. Selected Examples
Medication products in the medical care “vortex”

12. Predictable problems: Insulin brand names
Humulin “Log” ordered instead of Humulin-L (Lente).
Nurse thought Humalog” was to be given.

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

14. Dosage form names: OxyContin and MSContin

15. Dosage form names: Just a matter of time……
0.5mg, 1mg, 2mg, 3mg tablets XR

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

17. Technology-drug product interface: Levophed for Lopressor

18. 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

19. 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.

20. 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.