Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check.

BACKGROUND: Confusion resulting from look-alike and sound-alike drug names and look-alike product packaging can result in potentially harmful medication errors. CASE STUDY: A 69-year-old woman admitted to the oncology unit at a 670-bed teaching facility for correction of electrolyte imbalances was mistakenly administered Primacor instead of potassium chloride, reflecting a look-alike packaging medication error. ACTIONS TAKEN: The medical center developed and implemented process changes, including moving and reorganizing shelf storage bins, enhancing labeling for intravenous medications with similar packaging, tracking and responding to automated dispensing cabinet-filling errors, and revising processes for selecting and maintaining the list of look-alike, sound-alike medications to include the "real time" review of new medications added to the formulary and changes in packaging resulting fron contract changes or drug shortages. DISCUSSION: The Joint Commission National Patient Safety Goals for 2005 require organizations to identify and, at a minimum, annually review a list of look-alike sound-alike drugs and to proactively implement safety strategies to help prevent medication errors involving these drug combinations. Proactive assessment of potential for medication errors should include evaluation of potential look-alike packaging problems in addition to the drug names.