Professional Documents
Culture Documents
The Community Pharmacy Incident MULTI-INCIDENT ANALYSIS OF nological factors and (4) unique
Reporting (CPhIR) Program MEDICATION INCIDENTS RELATED factors, as shown in Table 2. (Note:
(available at http://www.cphir.ca) is TO LOOK-ALIKE/SOUND-ALIKE The “Incident Examples” provided
designed for community pharmacies DRUG NAMES IN COMMUNITY in Table 2 were limited by what was
to report near misses or medication PHARMACY PRACTICE inputted by pharmacy practitioners
incidents anonymously to ISMP to the “Incident Description” field
Canada for further analysis and Reports of medication incidents of the CPhIR program.)
dissemination of shared learning involving “look-alike/sound-alike”
from incidents.4 CPhIR has allowed were extracted from the CPhIR HIERARCHY OF EFFECTIVENESS
the collection of invaluable informa- Program from April 2010 to March IN PREVENTING MEDICATION
tion to help identify system-based 2012. In total, 540 incidents were INCIDENTS ASSOCIATED
vulnerable areas in order to prevent retrieved and 342 incidents met WITH LOOK-ALIKE/SOUND-
medication incidents.4 This article inclusion criteria and were included ALIKE DRUG NAMES
provides an overview of a multi- in this qualitative, multi-incident
incident analysis of medication analysis. They were independently Many possible recommendations
incidents involving look-alike/ reviewed by two ISMP Canada with varying degrees of effective-
sound-alike drug names reported to Analysts and categorized into four ness are available to prevent
the CPhIR program. main themes: (1) individual factors, medication errors. It is often
(2) environmental factors, (3) tech- difficult to select the best strategy
A prescription was written for • Knowledge deficit In order to clearly indicate medication,
Mebendazole 100mg, 2 doses with dosage, and instructions on prescrip-
2 weeks apart. The pharmacist • Confirmation bias tions, physicians should consider using
interpreted the prescription as standardized pre-printed order forms.1
metronidazole 1000mg, 2 doses • Illegible handwriting on the
with 2 weeks apart. The prescriber’s prescription Warning flags should be incorporated
handwriting was hard to read, and into the pharmacy computer systems to
Metronidazole was commonly • Lack of independent double alert for potential mix-up during drug
prescribed by this prescriber. When checks selections.3
the pharmacist was discussing with
the patient in terms of therapeutic Independent double checks should
indications of the prescription, it be performed throughout the entire
was discovered that the patient was pharmacy workflow.5 This may include
supposed to be treated for worms, a verification with the patient or the
not bacterial infection. patient’s agent regarding the indication
of the medication during drop-off or
A physician wrote a prescription for pick-up of prescription.
Hydrocortisone 1% in Mycostatin®;
however, Hydrocortisone 1% in To avoid incidents related to confirma-
Miconazole (Monistat®) was filled. tion bias, indications for each medication
The pharmacy staff member thought should be included on the prescription.3
Mycostatin® and Miconazole were
the same thing. It is recommended to highlight informa-
tion related to look-alike/sound-alike
drug names as part of pharmacy staff
training and communications.6
A pregnant patient was prescribed • Confirmation bias To avoid incidents related to confir-
Diclectin®, but Dicetel® was filled. The mation bias, indications for each
patient had been on Dicetel® many • Lack of independent double medication should be included on the
times in the past. checks prescription.3
A pharmacy student entered two • Fill multiple prescriptions The pharmacy dispensing environment
prescriptions correctly for the same for the same patient should be organized to create a safe
patient. The technician who was filling simultaneously and efficient working area.
prescriptions scanned out the proper
drugs, but mislabeled vials with each • Environmental distractions
other’s label. The pharmacist found out
the mistake while checking prescrip-
tions.
Due to the shortage of Apo®-Amilzide, • Drug shortage The look-alike/sound-alike drug pairs
Novamilor was filled for the patient. should be stored in separate loca-
When Apo®-Amilzide became available, • Proximity of storage of tions or in non-alphabetical order on
the pharmacy staff member planned look-alike/sound-alike drug shelves.6
to switch back to it. However, the pairs
Apo®-Amiloride was chosen instead of Independent double checks should
Apo®-Amilzide. Apo®-Amilzide was a • Lack of independent double be performed throughout the entire
combination drug including amiloride checks pharmacy workflow.5 This may include
and hydrochlorothiazide. Patient a verification of patient’s prior medica-
noticed the yellow color tablets when tion use in the patient profile prior to
picking up the prescription and ques- dispensing.
tioned the pharmacist. The patient’s
profile was checked and the error was
noticed.
for each situation. However, it is recommended to communication, but it relies in some part on human
choose the most effective solution that is reasonable vigilance and memory.9
and/or possible given the circumstances.8 Based on • “Reminders, Checklists, Double Checks” and “Rules &
the potential contributing factors that have been Policies” are often used to remind or control people,
identified from this multi-incident analysis, the follow- not necessarily to fix systems. Therefore, they should
ing hierarchy of effectiveness in preventing medication be used primarily to support more effective recom-
incidents associated with look-alike/sound-alike drug mendations that are designed to fix systems.9
names is summarized in Table 3. The recommenda- • “ Education & Information” is an important strategy
tions are listed in order from the most effective to the when it is combined with other approaches that
least effective solution. For example: strengthen the system.9
• “Simplification / Standardization” helps eliminating Although all the listed actions can play important roles
illegible handwriting and standardizing safe order in error prevention, it is recommended to select the
A patient took Tri-Cyclen® LO • Confirmation bias The copy functionality is available in all
before and received a new pharmacy software systems to enhance
prescription from the doctor for • Copying previous pharmacy workflow. In order to prevent
Tri-Cyclen®. The pharmacy staff prescriptions confirmation bias, policies may be considered
member copied from previous within the pharmacy to limit the process of
prescription on patient’s profile • Lack of independent double copying from previous prescriptions (where
and filled as Tri-Cyclen® LO. The checks applicable). The inputted prescription infor-
patient noticed the medication mation should be verified against the original
package was the same as before prescriber-generated prescription order.
and was anticipating a change.
The patient returned to the When providing medication counselling,
pharmacy before she took the pharmacists should encourage patients/
pills. caregivers to actively participate in the
conversation (e.g. confirm the appearance of
the medication, discuss the use, and verify
indication and appropriate technique for
administration of the medication, etc.)1
A patient called the pharmacy • Confirmation bias Independent double checks should be
to refill Zopiclone; however, the performed throughout the entire pharmacy
technician refilled the existing •Lack of independent double workflow.5
prescription for Zoloft® (Sertra- checks
line). When the patient got For verbal prescriptions, order takers should
home, she realized that she got be able to increase the source volume or
the wrong medication. have quiet areas to take orders. Spoken
communication of drug names can be made
safer by reading-back, spelling out the name,
providing the indication for the drug or using
both brand and generic names.7 Alternatively,
encourage patients to use Prescription
Numbers when ordering refills over the
phone.
most effective solutions that are designed to develop from look-alike/sound-alike drugs names as seen in
system-based improvements. Table 3. Everyone in healthcare has a role in reduc-
ing medication errors. The benefits of empowering
CONCLUSION and encouraging consumers to ask questions about
their medications should not be underestimated as
Look-alike/sound-alike drug names continue to patients play a key role in advancing safe medication
be an inevitable issue that often lead to negative practices. The results of this multi-incident analysis
impacts on patient safety. A multifactorial approach are intended to educate health care professionals
is essential to overcome the threats to patient safety about the vulnerabilities within our healthcare
The prescription was written for • The look-alike/sound-alike Warning flags should be incorporated
Hydrocortisone 1% ointment; however, drug pairs has similar or into the pharmacy computer systems
Hydrocortisone 1% cream was same therapeutic indica- to alert for potential mix-up during
dispensed. tions drug selection.3
A patient was prescribed Carbamaze- • The look-alike/sound-alike Auxiliary alerts should be placed on
pine CR 200mg; but Carbamazepine drug pair is available in medication storage bins or shelves,
200mg was dispensed. similar or same strength where look-alike/sound-alike drugs
are potentially stored.1
A pharmacist dispensed Advair® 250 • The same active ingredient
Diskus instead of Advair® 250. The is available in multiple Independent double checks should
second pharmacist noticed the error formulations be performed throughout the entire
and corrected it before giving to the pharmacy workflow.5
patient. • Lack of independent double
checks
• Include both generic and brand names in pharmacy Simplification / Highest Leverage
order entry system Standardization
References
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safetyBulletins/ISMPCSB2007-02Ephedrine.pdf
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patientsafetyinstitute.ca/English/toolsResources/IncidentAnalysis/Documents/
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ISMP Canada Safety Bulletin 2005; 5(1):1-2. Available from: http://www.ismp-canada.
org/download/safetyBulletins/ISMPCSB2005-01.pdf