Episode #157 Keeping Patients Safe from Look-Alike, Sound-Alike Medications

July 4, 2023

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Welcome 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 again 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.

Thank you so much to Tricia Meyer for contributing audio clips to the show today.

Check out Figure 4 in the article which includes a list of medications used in the perioperative setting with Tall Man Lettering.

Figure 4: Tall Man Lettering of some drugs used in the perioperative setting. (https://www.asahq.org/standards-and-guidelines/statement-on-labeling-of-pharmaceuticals-for-use-in-anesthesiology ) (Reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973).

Figure 4: Tall Man Lettering of some drugs used in the perioperative setting. (https://www.asahq.org/standards-and-guidelines/statement-on-labeling-of-pharmaceuticals-for-use-in-anesthesiology ) (Reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973).

It is important to keep in mind that LASA medications errors may occur at every stage of the medication use process including procuring, prescribing, ordering, verifying, dispensing, administering, and stocking and storing. The ISMP and other groups have come up with some strategies to help decrease medications errors at each of these steps. Check out the ISMP recommendations here. https://www.ismp.org/resources/adopt-strategies-manage-look-alike-andor-sound-alike-medication-name-mix-ups

For more information, please visit the APSF website “Look-Alike Drug Vial: Latest Stories & Gallery” at: https://www.apsf.org/look-alike-drugs/#gallery

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© 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. Last week, we talked about Look-Alike and Sound-Alike or LASA medications which include the following:

  1. Medications with similar physical appearance related to the packaging
  2. Medications with similar names in spelling
  3. Medications with similar phonetic pronunciation.

We also discussed preventive techniques including education and tools to decrease the risk of drug errors from LASA medications. Remember, the Joint Commission recommendation is for all hospitals to have a personalized LASA list of medications. In addition, hospitals need to use internal error reports associated with LASA drugs and review and maintain an up-to-date LASA list of medications. Do you know if your hospital does this? When was the last time your LASA list of medications was reviewed? This week, we have more preventive techniques to discuss. So, stay tuned!

Before we dive into the episode today, we’d like to recognize BD, a major corporate supporter of APSF. BD has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, BD – we wouldn’t be able to do all that we do without you!”

Our featured article today is once again “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. I will include a link in the show notes as well.

And now it’s time to get back into the article. Another way the US Food and Drug Administration is working to decrease medication errors from LASA drugs is by using “tall man lettering” or TML system for drug names that are similar in appearance or sound. The TML system uses uppercase lettering in a portion of the drug labeling where confusion or mistakes may occur. The authors provide the example of the written appearance of dexmedetomidine and dexamethasone which appear similar and may lead to confusion. Using the TML system, these drug names would appear as dexmedetomidine with a capital TOM and dexamethasone with a capital THASONE so that when you read the label, your attention is drawn to the parts of the medications names that are dissimilar. The medications that have the TML system for this labeling modification are chosen due to similarities in the spelling of the medication name, especially if these similarities have resulted in a reported drug error in the past.

Another tool created by the FDA is a computer analysis tool that measures the phonetic and orthographic similarities of the planned brand name of the medication compared to datasets from different sources that include pre-existing drug brand and generic names. This tool may be helpful to develop proprietary names for new medications that are less likely to cause errors.

The American Society of Anesthesiologists has recently updated their statement on labeling of pharmaceuticals for use in anesthesiology in 2020 which provides education on the dangers of LASA drugs and includes a list of medications that are used during anesthesia care that have been identified as high risk for LASA. Check out Figure 4 in the article which includes a list of medications used in the perioperative setting with Tall Man Lettering. I will include this Figure in the show notes as well.

Here are some of the medications on this list:

  • Cefazolin, Cefotetan, Cefoxitin, Ceftazidime, Ceftriaxone
  • Clonidine, Quinidine
  • Dexamethasone, Dexmedetomidine, Diphenhydramine
  • Diazepam, Diltiazem, Lorazepam
  • Nifedipine, Nicardipine
  • Dobutamine, Dopamine
  • Ephedrine, Epinephrine
  • Fentanyl, Sufentanil
  • Humalog, Humulin
  • Hydralazine, Hydromorphone, Hydroxyzine
  • Solucortef, Solumedrol

The Institute for Safe Medication Practices (ISMP) has developed a list of often confused drug names related to look-alike and sound-alike characteristics. I will include a link in the show notes so that you can check this out. It would be very challenging to develop a list of medications that share similar appearances in packaging since there is a lack of standardization of packaging.

It is important to keep in mind that LASA medications errors may occur at every stage of the medication use process including procuring, prescribing, ordering, verifying, dispensing, administering, and stocking and storing. The ISMP and other groups have come up with some strategies to help decrease medications errors at each of these steps. Do you know which stage is the most difficult to catch a medications error?

If you said, “administering”, you would be correct.

Now, let’s go through some of the preventive strategies now from the Institute of Safe Medication Practices. We’ll start with purchasing. Here are the strategies:

  • Avoid stocking/purchasing medications in which the manufacturer’s trademark symbol/logo is larger than name of product.
  • Ensure that names are evaluated by practitioners who use them before adding to formulary/inventory.
  • Ask pharmacy to identify LASA concerns for medications that are new or shortage substitutes

Next up, the authors review strategies to help decrease LASA medication errors during the ordering and prescribing steps.

  • Avoid abbreviations (e.g., MgSO4, TXA), stemmed, or stems (e.g.,“caines”), or shortened names (e.g., “dex”). Communicate the full generic name and/or brand name.
  • Brand and generic name should be displayed for problematic look-alike names in the medication description field, on product selection menus, and for search choices
  • Build order sets with the indications for problematic names (e.g., hydrOXYzine for pruritus, hydrALAZINE for hypertension).

We have made it to the highly vulnerable step of administration. Here are some strategies to help keep patients safe while administering medications.

  • Before administering a medication, read the container and/or pharmacy label when obtaining from unit stock or AMDC. Never rely solely on a partially turned label, the color of a label/cap, the auxiliary warning, or company graphics to identify a product.

The next area is stocking and storing. There are a couple of strategies that can help to decrease drug errors at this stage including

  • In anesthesia carts/trays, organize vials in a label-up instead of cap-up position, and avoid close proximity with LASA names (or look-alike packaging and labeling, particularly cap colors)

Are you using these at your institution? Go ahead and open up your anesthesia drug cart to find out.

Finally, we made it to nomenclature. The authors provide a couple of preventive measures that may help when it comes to drug names.

  • For problematic look-alike medication names, use tall man lettering on electronic prescribing drug selection screens, order sets, AMDC screens, smart infusion pump screens, medication administration records, and any other drug communication tools.
  • If short names are permitted to search for products or populate fields without entering the full medication name, require practitioners to enter at least 5 letters during a drug name search to reduce the number of medications, including those with LASA names, that appear together on a screen.
    (https://www.ismp.org/resources/adopt-strategies-manage-look-alike-andor-sound-alike-medication-name-mix-ups)

We made it to the end of the article and the authors leave us with a call to action that is especially important since LASA medication errors are a preventable threat to anesthesia patient safety. The responsibility does not just lie with the anesthesia professionals in the operating room though. Plus, we reviewed many strategies today for each stage of the medication use process, but these may be challenging to implement depending on the different preoperative, intraoperative, and postoperative settings. There also may not be anything that we can do to change drug names that have look alike and sound-alike implications. Thus, it is imperative for health care professionals, safety groups, and professional organizations to continue to work with manufacturers, regulators, and naming entities to decrease the look-alike and sound-alike risks for medications that are new to market or in the pre-marketing stage. This is a vital step towards improving medication safety going forward.

Before we wrap up for today, I also asked Meyer what she hopes to see going forward related to medication safety. Here’s what she had to say.

[Meyer] “Well, there’s no easy answer for solving the LASA drug problem. With over 20,000 prescription drugs on the market and new drugs being launched every year, LASA ERAS will continue to increase the A P S F medication Advisory group, recommend implementation of point of care, electronic medication scanning.

For medication checks and clinical decision support prior to administration with auditory and displayed medication name and alerts to decrease medication errors. Additionally, the Institute for Safe Medication Practices has developed strategies for every phase of the medication process to prevent less errors.

Such as organizing vows in a label up position instead of a CAPA position in drug trays, carts in other locations. If Lassa drug naming and packaging risk could be further evaluated and minimized by drug manufacturers prior to new medications reaching the market, this would be an optimal approach to assist in the LASA drug dilemma.”

[Bechtel] Thank you so much to Meyer for contributing to the show today. We hope to see improved medication safety with LASA drugs going forward and there are many strategies that we talked about today that can be used to help keep patients safe.

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.

If you have not done so already, we hope that you will rate us and leave a review on iTunes or wherever you get your podcasts and feel free to share this podcast with your friends and colleagues and anyone that you know who is interested in anesthesia patient safety. Plus, you can let us know that you are listening by tagging us @APSForg using the hashtag #APSFpodcast.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2023, The Anesthesia Patient Safety Foundation