Medication errors similarity

H. influenzae type b and influenza vaccines have the potential for confusion and medication errors because of the similarity of the names. Care should be taken when ordering, dispensing, and administering these vaccines. 

Figure 30-6. Similar packaging might lead to medication errors.

Numerous reports of medication errors are being reported, some of which have resulted in patient injury or death. In a number of these reports, a medication was mistakenly administered either because the drug container (bag, ampule, prehlled syringe and bottle) was similar in appearance to the intended medication s container or because the packages had similar labeling. Obviously, the severity of such errors depends largely on the medication administered. 

Report any information relating to medication errors to the Medication Errors Reporting Program operated by USP convention [10] and the Institute for Safe Medication Practice (ISMP) or other corresponding institutions in the different countries. The program shares information on medication errors with health care professionals to prevent similar errors from recurring. 

Verbal orders are oral communications between senders and receivers in person or by telephone or other similar devices. The National Coordinating Council for Medication Error Reporting and Prevenhon (NCC MERP) developed recommendations to reduce errors related to verbal orders. Table 16.4 notes the elements that should be included in a verbal order. Table 16.5 outlines NCC MERP s additional recommendations. ... 

The Medication Error Reporting Program (MERP) is a voluntary program administered by the U.S. Pharmacopeia (USP) in conjxmction with the ISMP. This confidential reporting system improves patient safety by alerting practitioners and the industry to potential or actual problems. Practitioners are asked to report errors and near misses to this program so that others learn from errors and prevent similar errors in the future. 

The sentinel event reports submitted to the JCAHO are reviewed and cataloged for error type and underlying causes. Medication errors are one of the most common types of sentinel events reported to the JCAHO. When a trend of similar errors is identified, the JCAHO issues a sentinel event alert, which alerts others of the risk and recommends actions to minimize risk in organizations. The first alert issued in 1998 focused on deaths due to the inadvertent IV push administrahon of IV potassium chloride (KCl). Awareness of these events and actions by pharmacists to remove concentrated KCl from patient unit floor stocks has markedly reduced reports of this type of error. Of the 27 subsequent alerts issued in January 2003, seven focus on different types of medication errors and prevention strategies. 

Healthcare professionals can either complete a report form or contact the ISMP—Spain directly by e-mail, fax, or telephone to report medication errors with complete confidentiality. The types of medication errors submitted include confusion over look-alike or sound-alike drug names, ambiguity or similarity in packaging or labeling. 

Medical error is an umbrella term given to all errors that occur within the healthcare system, including mishandled surgery, diagnostic errors, equipment failures and medication errors. As medicines are the most common interventions in the healthcare system, medication errors are probably one of the most common types of medical error. Research suggests that approximately 7000 patients a year are killed by medication errors in the USA (Kohn et ai, 1999), and in British hospitals the incidence and consequences appear to be similar (Cowley et ai, 2001 Dean et ai, 2002). 

Although relatively few studies have focused on nurses or other professions, studies that do exist suggest that nurses also suffer similarly in the aftermath of errors. Not surprisingly they experience the same basic human responses of shame, guilt and anxiety about the consequences. In one study on medication error, nurses were more likely than doctors or pharmacists to report strong emotional responses to making an error and fear of disciplinary aaion or punishment (Wolf et ai, 2000 White et ai, 2008), which perhaps reflects the different disciplinary culture of nursing. 

While medication errors and medication processes have received most attention, achievements have not been confined to medication safety. Box 11.4 shows an example of a similarly sustained and radical change in the interpretation of radiographs. As so often happens, healthcare processes had evolved and adapted over time, rather than being designed to produce a certain... 

Medication errors involving look-alike/sound-alike drug names can cause serious patient harm. For instance, a number of errors have been reported and published on the confusion between Lamisil and Lamictal . Reading these two names quickly, one can easily see how they could be confused, but re-design of the labels to highlight the differences rather than the similarities makes them markedly distinct (Figure 12.1). 

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