Medication Errors

Look-Alike/Sound-Alike
Medications

Krystle Barroga, Erin Chun,

Michelle Popek, Kate Takahashi,
Sonia Lipka

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

Qual i ty Improvement Too l

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

Medications
stored in order,
alphabetically

Medications
sound and look
alike

High acuity,
short staffed

No specific
indication for
medication

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.

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

CHECK
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 inservices
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/0/434/436/440/6276/6334/6350/6356/8b8dac7
6-6061-4521-8b43-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 120:40610.
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-drugname-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.13652702.2012.04344.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/