The existence of look alike and sound alike drug names is a one of the most common causes of medication error and is of concern worldwide. As more medicines and new brands are being marketed in addition to the thousands already available. Many of these medication names may look or sound alike. Thus, the potential for error due to confusing drug names is very high. According to the survey from United States Pharmacopoeia, around commonly used medications were involved in such errors. Error prone medication pairs that can easily cause confusion while prescribing, dispensing and administration/consumption were sorted out. Also real life experiences of medication errors and near misses due to error prone drug pairs were collected from the doctors and the dispensers. It is very important that we circulate the list of confusing brand names among the practicing doctors, pharmacists and also to the drug manufacturers. Preventing confusion between already marketed products typically involves collecting voluntary reports of names involved in confusion errors, posting warnings and alerts both electronically and in areas where drugs are used. The fear of malpractice lawsuits and public embarrassment has made the physicians and nurses reluctant to report medication errors. It is more important to create the open environment that encourages the reporting of errors than to develop less meaningful comparative error rates. One possible approach to improving medical error reporting systems. This type of system should also enable internal tracking, trending and comparative analyses. We need to have such system in India.
2. DEFINITION
The existence of confusing drug names is one of
the most common causes of medication error and is
of concern worldwide
Some proprietary (brand name) and non-proprietary
names (generic name) sound or appear to be
similar to other drugs when written or spoken.
3. These confusing drug names are one of the main causes
of medication error. There are many sound and look alike
drugs that would result in medication error. These errors
may cause harm or even death to patients.
According to the results from United States
Pharmacopoeia, around 1400 commonly used
medications were involved in such errors.
6. SOURCE OF ERROR
The main reasons for improper dispensing of
confusing brand names, may be due to negligence or
due to lack of knowledge of registered pharmacist or
due to less number of pharmacist during rush hours.
When brand names of two or more drugs are similar.
Faulty dispensing would result from one of the
following situation:
Illegible handwriting of the prescribing physician (reading &/or
writing error).
Incorrect dispensing by the pharmacist due to over sight
(similar looking name).
Incorrect reading of the brands name by the patient while
ordering the medicine by phone, which is a common practice
in some cities in this country (similar sounding name)
7. ERROR PRONE DRUG PAIRS
Error prone medication pairs that can easily cause confusion while
prescribing, dispensing and administration/consumption were sorted
out. Also real life experiences of medication errors and near misses
due to error prone drug pairs were collected from the doctors and the
dispensers.
1. LASA drugs-Similar brand names, different generic
composition (Category I)
2. LASA drugs- Similar brand names, same generic composition
(Category II)
3. LASA drugs- Similar brand names with additional letter
(Category III)
4. LASA drugs- Similar brand names of the Antibiotics group
(Category IV)
5. LASA drugs- Same drug, different Dosage forms
(Category V)
6. LASA drugs- Same drug, different release characteristics
(Category VI)
7. LASA drugs- Same brand name, different composition, different
country (Category VII)
8. LASA drugs- Generic Drug pairs (Category VIII)
16. 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
17. 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
18. PREDICTABLE PROBLEMS:
Insulin brand names
•Humulin “Log” ordered instead of Humulin-L (Lente).
•Nurse thought Humalog” was to be given.
23. POSSIBLE SOLUTIONS
1. Identification of LASA medications: Create the
awareness of look-alike and sound-alike medicines in
the prescribers; if possible provide a detailed list of drug
names pairs in the local market
2. Prescriber’s role: Try to use legible handwriting while
prescribing, keeping in mind as if one was writing bank
cheques. Writing trade names (UPPER CASE)
accompanied by generic names, dosage form, strength,
directions and indication for use when possible.
3. Pharmacist’s/dispenser’s role: Provided that there is
dose and other details in the prescriptions he/she
should make use of his/her knowledge to identify the
drug prescribed. In case of uncertainty in medicine
names, they should not hesitate to consult the
prescribing doctor before dispensing
24. 4. Patient’s role: Literate patients can themselves check if
the dispensed product is the same as prescribed. Patients
who cannot read and write should better consult other
sources for verification before taking the medicines.
5. Hospital’s or institution’s role: Provide education on
potential LASA medicines. continuing professional
development for health-care professionals and annually
review the list of LASA medicines used in the institution.
Try and reduce the medical transcription by the nursing
staff and rather initiate dispensing only against a proper
prescription by a licensed doctor. Use of printed order or
electronic prescribing. the less important drug in the LASA
pair can be removed.
6. Manufacturer’s and regulatory agency’s role: The
manufacturers and regulatory agencies both should work
together hand in hand to avoid confusion right at the time
of naming their products.
25. WHAT IS TALL MAN LETTERING?
• It is an error-prevention strategy used as part of a
multi-faceted approach to reduce the risk of look-
alike and sound-alike medicine name confusion and
errors.
• It is a typographic technique that uses selective
capitalisation to help make similar-looking medicine
names easier to differentiate.
• Its purpose is to help select or supply the right
medicine.
26.
27.
28. HOW DOES IT WORK?
Tall Man lettering combines lower-
and upper-case letters to highlight
the differences between look-alike
and sound-alike medicine names,
like fluOXETine and
fluVOXAMine, making them easier
for the eye to distinguish.
29. PATIENT SAFETY SOLUTION.
Pharmacist/nurses
Keeping LASA drugs separated from one another
Double checking of drugs
Contacting the physician in case of any clarification
regarding the prescription
Becoming familiar with LASA drugs
Minimize the use of verbal and telephone orders.
30. ON THE CLOSING NOTE
It is very important that we circulate the list of confusing brand
names among the practicing doctors, pharmacists and also to the
drug manufacturers. Preventing confusion between already
marketed products typically involves collecting voluntary reports
of names involved in confusion errors, posting warnings and
alerts both electronically and in areas where drugs are used.
The fear of malpractice lawsuits and public embarrassment has
made the physicians and nurses reluctant to report medication
errors. It is more important to create the open environment that
encourages the reporting of errors than to develop less
meaningful comparative error rates.
One possible approach to improving medical error reporting
involves the use of anonymous standardized reporting systems.
This type of system should also enable internal tracking, trending
and comparative analyses. We need to have such systems in
India.