Literature DB >> 22193703

Look-alike and sound-alike medicines: risks and 'solutions'.

Lynne M Emmerton1, Mariam F S Rizk.   

Abstract

'Look-alike, sound-alike' medicines are associated with dispensing errors. This commentary aims to fuel discussion surrounding how drug name nomenclature and similar packaging between medicines can lead to selection errors, the need for enhanced approval systems for medicine names and packaging, and best practice 'solutions'. The literature reveals a number of environmental risks and human factors that can contribute to such errors. To contextualise these risks, we interviewed 13 quality and safety experts, psycholinguists, and hospital and community pharmacy practitioners in Australia, and commissioned a medical software industry expert to conceptualise electronic initiatives. Environmental factors contributing to such errors, identified through both the literature and interviews, include distractions during dispensing; workflow controls should minimise the 'human factors' element of errors. Technological solutions with some support, and yet recognised limitations, include font variations, automated alerts, barcode scanning and real-time reporting programmed into dispensing software; further development of these initiatives is recommended.

Entities:  

Mesh:

Year:  2012        PMID: 22193703     DOI: 10.1007/s11096-011-9595-x

Source DB:  PubMed          Journal:  Int J Clin Pharm


  10 in total

1.  Human error: models and management.

Authors:  J Reason
Journal:  BMJ       Date:  2000-03-18

2.  Similarity as a risk factor in drug-name confusion errors: the look-alike (orthographic) and sound-alike (phonetic) model.

Authors:  B L Lambert; S J Lin; K Y Chang; S K Gandhi
Journal:  Med Care       Date:  1999-12       Impact factor: 2.983

3.  Look-alike and sound-alike drugs: errors just waiting to happen.

Authors:  Nancy Tuohy; Susan Paparella
Journal:  J Emerg Nurs       Date:  2005-12       Impact factor: 1.836

4.  Confusing, look-alike, and sound-alike medications.

Authors:  Suzanne C Beyea
Journal:  AORN J       Date:  2007-11       Impact factor: 0.676

5.  USP says thousands of drug names look or sound alike.

Authors:  Cheryl A Thompson
Journal:  Am J Health Syst Pharm       Date:  2008-03-01       Impact factor: 2.637

Review 6.  Incidence, type and causes of dispensing errors: a review of the literature.

Authors:  K Lynette James; Dave Barlow; Rowena McArtney; Sarah Hiom; Dave Roberts; Cate Whittlesea
Journal:  Int J Pharm Pract       Date:  2009-02

7.  Labeling of medicines and patient safety: evaluating methods of reducing drug name confusion.

Authors:  Ruth Filik; Kevin Purdy; Alastair Gale; David Gerrett
Journal:  Hum Factors       Date:  2006       Impact factor: 2.888

8.  The role of typography in differentiating look-alike/sound-alike drug names.

Authors:  Sandra Gabriele
Journal:  Healthc Q       Date:  2006

Review 9.  Medication errors caused by confusion of drug names.

Authors:  James M Hoffman; Susan M Proulx
Journal:  Drug Saf       Date:  2003       Impact factor: 5.606

10.  Drug name confusion: evaluating the effectiveness of capital ("Tall Man") letters using eye movement data.

Authors:  Ruth Filik; Kevin Purdy; Alastair Gale; David Gerrett
Journal:  Soc Sci Med       Date:  2004-12       Impact factor: 4.634

  10 in total
  16 in total

1.  Safeguarding the process of drug administration with an emphasis on electronic support tools.

Authors:  Hanna M Seidling; Anette Lampert; Kristina Lohmann; Julia T Schiele; Alexander J F Send; Diana Witticke; Walter E Haefeli
Journal:  Br J Clin Pharmacol       Date:  2013-09       Impact factor: 4.335

2.  A comparison of the effects of different typographical methods on the recognizability of printed drug names.

Authors:  Calvin K L Or; Hailiang Wang
Journal:  Drug Saf       Date:  2014-05       Impact factor: 5.606

3.  Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports.

Authors:  Alison Cooper; Adrian Edwards; Huw Williams; Huw P Evans; Anthony Avery; Peter Hibbert; Meredith Makeham; Aziz Sheikh; Liam J Donaldson; Andrew Carson-Stevens
Journal:  Age Ageing       Date:  2017-09-01       Impact factor: 10.668

4.  Dispensing errors from look-alike drug trade names.

Authors:  Hsiang-Yi Tseng; Chen-Fan Wen; Ya-Lun Lee; Kee-Ching Jeng; Pei-Liang Chen
Journal:  Eur J Hosp Pharm       Date:  2016-11-22

5.  Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets.

Authors:  Henna Karoliina Ruutiainen; Miia Marjukka Kallio; Sini Karoliina Kuitunen
Journal:  Eur J Hosp Pharm       Date:  2021-01-15

6.  Look-alike, sound-alike medication errors: a novel case concerning a Slow-Na, Slow-K prescribing error.

Authors:  Mark Naunton; Hayley R Gardiner; Greg Kyle
Journal:  Int Med Case Rep J       Date:  2015-02-16

7.  Assessment of Orthographic Similarity of Drugs Names between Iran and Overseas Using the Solar Model.

Authors:  Nazanin Abolhassani; Ali Akbari Sari; Arash Rashidian; Mansoor Rastegarpanah
Journal:  Iran J Public Health       Date:  2017-12       Impact factor: 1.429

8.  Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names.

Authors:  Rachel Bryan; Jeffrey K Aronson; Pius ten Hacken; Alison Williams; Sue Jordan
Journal:  PLoS One       Date:  2015-12-23       Impact factor: 3.240

Review 9.  Reducing medication errors in critical care: a multimodal approach.

Authors:  Rachel M Kruer; Andrew S Jarrell; Asad Latif
Journal:  Clin Pharmacol       Date:  2014-09-01

10.  Case report of a medication error: In the eye of the beholder.

Authors:  Mark Naunton; Kowsar Nor; Andrew Bartholomaeus; Jackson Thomas; Sam Kosari
Journal:  Medicine (Baltimore)       Date:  2016-07       Impact factor: 1.889

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