Episode #156 Medication Errors Related to Look-Alike, Sound-Alike Drugs
June 27, 2023Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel. This podcast will be an exciting journey towards improved anesthesia patient safety.
Are you ready to open up the June 2023 APSF Newsletter? Our featured article today is “Medication Errors Related to Look-Alike, Sound-Alike Drugs—How Big is the Problem and What Progress is Being Made?” by Tricia A. Meyer, PharmD, MS, FASHP; Russell K. McAllister, MD, FASA.
Let’s define LASA medications which include the following:
- Medications with similar physical appearance related to the packaging
- Medications with similar names in spelling
- Medications with similar phonetic pronunciation.
Here are the citations that we talked about on the show today:
- Institute for Safe Medication Practices (ISMP). Dangerous errors with tranexamic acid. ISMP Medication Safety Alert! Acute Care.2019;24:1–2. https://www.ismp.org/alerts/dangerous-wrong-route-errors-tranexamic-acid. Accessed March 17, 2023.
- Palanisamy A, Kinsella SM. Spinal tranexamic acid–a new killer in town. Anaesthesia. 2019;74[7]:831-3
- Patel S. Cardiovascular drug administration errors during neuraxial anesthesia or analgesia—a narrative review. J Cardiothor Vasc Anesth.2023;37:291–298. PMID: 36443173
We hope that you check out the APSF’s Look-Alike Drug Vials: Latest Stories & Gallery. The following alerts and photos show how look-alike drug vials and packaging can contribute to medication errors and impact patient safety.
Be sure to check out the APSF website at https://www.apsf.org/
Make sure that you subscribe to our newsletter at https://www.apsf.org/subscribe/
Follow us on Twitter @APSForg
Questions or Comments? Email me at [email protected].
Thank you to our individual supports https://www.apsf.org/product/donation-individual/
Be a part of our first crowdfunding campaign https://www.apsf.org/product/crowdfunding-donation/
Thank you to our corporate supporters https://www.apsf.org/donate/corporate-and-community-donors/
Additional sound effects from: Zapsplat.
© 2023, The Anesthesia Patient Safety Foundation
Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. The June 2023 APSF Newsletter is here!! Wherever you are in the world, perhaps you are lounging pool side and kicking off summer or getting ready to hit the ski slopes heading into the winter season, we have some great articles for you! This is our first show featuring the new June 2023 APSF Newsletter articles and we are going to be talking about…well, I will leave you in suspense for a moment.
But before we dive into the episode today, you’ve heard me recognize our corporate supporters on this show, but there’s another supporter who is absolutely essential – YOU! Every individual donation matters so much. Please visit APSF.org and click on the Our Donors heading and consider making a tax-deductible donation to the APSF.
Are you ready to open up the June 2023 APSF Newsletter? Our featured article today is “Medication Errors Related to Look-Alike, Sound-Alike Drugs—How Big is the Problem and What Progress is Being Made?” by
Tricia Meyer and Russell K. McAllister. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the Current Issue. Then scroll down until you get to our featured article today. Before we get into the article, we have exclusive content from one of the authors. I will let her introduce herself now.
[Meyer] “Hello, my name is Tricia Meyer and I am a pharm d and an adjunct professor in anesthesiology for Texas a and m College of Medicine. I’m a member of the Anesthesia Patient Safety Foundation.”
[Bechtel] I asked Meyer why she wrote the article. Let’s take a listen to what she had to say.
[Meyer] “The perioperative area is one of the most medication intense locations in a hospital with more high alert medication administrations per patient, lookalike soundalike or LASA drugs, or common source of medication errors and estimated to make up as much as 25% of medication errors. A 2022 study found lasso drugs were a primary contributing factor for anesthesia substitution errors.”
[Bechtel] Thank you so much to Meyer for helping to kick off the show today. Don’t worry, we’ll be hearing more from her soon.
And now it’s time to get into the article. The author’s start with some background information about the scope of the problem. Medication errors may occur in any field of medicine, but the field of anesthesia is unique since anesthesia professionals are responsible for prescribing, preparing, and administering their own medications. With this great power to prescribe, prepare, and administer medications, comes great responsibility for anesthesia professionals to prevent medication errors. There are several reasons why medication errors may occur. Today, we are going to look closely at medication errors related to look-alike and sound-alike or LASA drugs and the similar appearance of the medication vials. Let’s define LASA medications which include the following:
- Medications with similar physical appearance related to the packaging
- Medications with similar names in spelling
- Medications with similar phonetic pronunciation.
We are unable to contain this problem due to ever-changing manufacturer trade names, new medications on the market, changes in packaging between different manufacturers, and constantly changing formulary at individual hospitals. Drug shortages add to the problem by forcing pharmacies to order medications from different suppliers in order to maintain the supply of medications. This may mean that all of a sudden a medication vial changes appearance in the anesthesia drug cart leading to increased risk for a medication error. Has this ever happened to you? You open up your anesthesia cart and reach down to grab a vial of ondansetron and the vials looks totally different? Did you receive notice about the change in ondansetron vial appearance? This is a big threat to anesthesia patient safety.
Let’s take a look at the literature on medication errors. We’ll start with the 2022 article published in Anesthesia and Intensive Care, “Analysis of medication errors during anesthesia in the first 4000 incidents reported to webAIRS” by Kim and colleagues. This study reviewed the first 4,000 incident reports in the WebAIRS anesthetic incident reporting system from Australia and New Zealand anesthesia professionals. The authors discovered 462 incidents involved medication errors. Incorrect dosing and substitution as the top-ranked error categories. A primary contributing factor for the substitution medication error was look-alike drugs.
Keep in mind that LASA-related drug errors may lead to worsen complications when they involve high alert medications like opioids, insulin, anticoagulants, or neuromuscular blocking drugs or hazardous medications like chemotherapy agents or potentially dangerous route of administration such as intrathecal. Another consideration is that each medication vial will have at least three names: the chemical name, the generic name which may vary by country, and more than one brand or trade name. Plus, medication vials may share similar appearances in terms of the color of the vial medication cap as well as similar labels. Check out Figures 1a, 1b, and 1c in the article for more examples. You may be able to just open up you anesthesia cart for additional examples and you can check out the APSF Look-alike Drug Vials: Latest Stories and Gallery. You can find this over at APSF.org by clicking on the Patient Safety Resources. The nineth one down is dedicated to look-alike drug vials. Thank you to all of the anesthesia professionals who have submitted stories and pictures to help improve patient safety.
Next up, the authors remind us that it is difficult to know exactly how many LASA drug errors occur, but it is estimated that 25% of medication errors are due to LASA drug errors. This may be one of the most common contributing factors for medication errors. We know that look alike and sound alike medications contribute significantly to medications errors, but so far regulatory agencies, hospitals, and practitioners have been unable to eliminate this big threat to patient safety.
Let’s review several cases of LASA errors to further illustrate the scope of the problem. First up, you may have heard about the recent fatal drug error when a nurse intended to give a benzodiazepine, Midazolam or Versed to a patient to treat procedural anxiety. The nurse entered the letters V-E into the automated medication dispensing cabinet and Vecuronium was offered by the dispensing cabinet as the medication option to dispense and this was chosen by the nurse. Then, she bypassed several safety measures in order to withdraw and then administer vecuronium instead of the intended versed to the patient which led to the ultimate demise of the patient. We have talked about this case before on the podcast on Episode #105 Criminalization of Medical Error: A Call to Action. We hope that you will check it out when you get a chance. The outcome of this case was that the nurse was tried and convicted of criminally negligent homicide. Key considerations in this case included unfamiliarity with the medications involved and bypassing multiple safety barriers from the automated medication dispensing cabinet and on the medication vial’s cap and label.
Another important LASA error is the inadvertent administration of the wrong medications into the intrathecal space. There are recent cases of tranexamic acid and digoxin being administered during an attempted spinal block procedure. Check out figure 2 from the article for an visual example of the look-alike vials of tranexamic acid, ropivacaine, and bupivacaine. Even though the label colors and vial sizes are different, the caps are all blue and when they are stored upright, they look the same which may lead to an error by selecting the wrong medication. Intrathecal administration of tranexamic acid may lead to seizures, permanent neurological injury, ventricular arrythmias, and paraplegia since it is a potent neurotoxin when given into the spinal space. There is also a 50% mortality rate. For more information, check out the ISMP alert from 2020 and the 2019 article, “Spinal Tranexamic Acid-A New Killer in Town.” I will include both citations in the show notes.
Intrathecal administration of digoxin may lead to paraplegia and encephalopathy. There are at least 8 cases of accidental intrathecal injection of digoxin and 33 cases of accidental cardiovascular drug administration via the spinal route leading to devastating outcomes. These are preventable medication errors and the most common contributing factor was incorrect visual inspection of look alike vials with the same vial cap color. Take a look at the 2023 article by Patel, “Cardiovascular drug administration errors during neuraxial anesthesia or analgesia—a narrative review.” You can find the citation in the show notes as well.
Another important LASA drug error was the administration of insulin instead of an influenza vaccine. This happened in a group care facility and for an employee group. Symptomatic patients required hospitalization. In both of these cases, the drug error was due to the similar appearance of the two vials.
Before we wrap up for today, we are going to talk about ways to prevent LASA errors. Medication safety is an important part of patient safety and LASA errors contribute significantly to this threat. The Joint Commission and the Food and Drug Administration in the United States have identified LASA drug errors as a focus in the past several years. Some preventive techniques highlighted by these organizations include education and tools to decrease the risk. Let’s take a look at some of these tools. The Joint Commission recommendation is for all hospitals to have a personalized LASA list of medications. This list must be personalized to the individual hospital to include only the medications that are administered at the individual sites. Hospitals need to use internal error reports associated with LASA drugs and review and maintain an up-to-date LASA list of medications. Does your hospital do this? Is your LASA list of medications reviewed at least annually?
We have many more tips and tricks for prevention of LASA errors and we are going to talk about them next week. Plus, we are going to hear from Tricia Meyer again. It’s going to be another great show that you don’t want to miss. Do you have a look alike vial story or picture? You can submit it to the APSF gallery. I will include a link to the submission in the show notes and you can browse the gallery for more information about look alike vials.
If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
The all-new June 2023 APSF Newsletter is here! We are so excited to continue to talk about the new articles with exclusive content from the authors right here on this podcast in the upcoming weeks!! In the meantime, we hope that you check out the new newsletter. For more anesthesia patient safety content all week long, we hope that you will follow us on twitter, @APSForg or you can like and share our posts on Instagram and Facebook. Before you know it, the next podcast episode will be ready to drop!
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
© 2023, The Anesthesia Patient Safety Foundation