Jessica M Zacher1, Francesca E Cunningham1, Xinhua Zhao2, Muriel L Burk1, Von R Moore1, Chester B Good3, Peter A Glassman4, Sherrie L Aspinall5. 1. VA Center for Medication Safety/Pharmacy Benefits Management Services, Hines, IL. 2. VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. 3. VA Center for Medication Safety/Pharmacy Benefits Management Services, Hines, IL, and VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. 4. VA Center for Medication Safety/Pharmacy Benefits Management Services, Hines, IL, and VA Greater Los Angeles Healthcare System, Los Angeles, CA. 5. VA Center for Medication Safety/Pharmacy Benefits Management Services, Hines, IL, and VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA sherrie.aspinall@va.gov.
Abstract
PURPOSE: Results of a study to estimate the prevalence of look-alike/sound-alike (LASA) medication errors through analysis of Veterans Affairs (VA) administrative data are reported. METHODS: Veterans with at least 2 filled prescriptions for 1 medication in 20 LASA drug pairs during the period April 2014-March 2015 and no history of use of both medications in the preceding 6 months were identified. First occurrences of potential LASA errors were identified by analyzing dispensing patterns and documented diagnoses. For 7 LASA drug pairs, potential errors were evaluated via chart review to determine if an actual error occurred. RESULTS: Among LASA drug pairs with overlapping indications, the pairs associated with the highest potential-error rates, by percentage of treated patients, were tamsulosin and terazosin (3.05%), glipizide and glyburide (2.91%), extended- and sustained-release formulations of bupropion (1.53%), and metoprolol tartrate and metoprolol succinate (1.48%). Among pairs with distinct indications, the pairs associated with the highest potential-error rates were tramadol and trazodone (2.20%) and bupropion and buspirone (1.31%). For LASA drug pairs found to be associated with actual errors, the estimated error rates were as follows: lamivudine and lamotrigine, 0.003% (95% confidence interval [CI], 0-0.01%); carbamazepine and oxcarbazepine, 0.03% (95% CI, 0-0.09%); and morphine and hydromorphone, 0.02% (95% CI, 0-0.05%). CONCLUSION: Through the use of administrative databases, potential LASA errors that could be reviewed for an actual error via chart review were identified. While a high rate of potential LASA errors was detected, the number of actual errors identified was low.
PURPOSE: Results of a study to estimate the prevalence of look-alike/sound-alike (LASA) medication errors through analysis of Veterans Affairs (VA) administrative data are reported. METHODS: Veterans with at least 2 filled prescriptions for 1 medication in 20 LASA drug pairs during the period April 2014-March 2015 and no history of use of both medications in the preceding 6 months were identified. First occurrences of potential LASA errors were identified by analyzing dispensing patterns and documented diagnoses. For 7 LASA drug pairs, potential errors were evaluated via chart review to determine if an actual error occurred. RESULTS: Among LASA drug pairs with overlapping indications, the pairs associated with the highest potential-error rates, by percentage of treated patients, were tamsulosin and terazosin (3.05%), glipizide and glyburide (2.91%), extended- and sustained-release formulations of bupropion (1.53%), and metoprolol tartrate and metoprolol succinate (1.48%). Among pairs with distinct indications, the pairs associated with the highest potential-error rates were tramadol and trazodone (2.20%) and bupropion and buspirone (1.31%). For LASA drug pairs found to be associated with actual errors, the estimated error rates were as follows: lamivudine and lamotrigine, 0.003% (95% confidence interval [CI], 0-0.01%); carbamazepine and oxcarbazepine, 0.03% (95% CI, 0-0.09%); and morphine and hydromorphone, 0.02% (95% CI, 0-0.05%). CONCLUSION: Through the use of administrative databases, potential LASA errors that could be reviewed for an actual error via chart review were identified. While a high rate of potential LASA errors was detected, the number of actual errors identified was low.
Authors: Bruce L Lambert; William Galanter; King Lup Liu; Suzanne Falck; Gordon Schiff; Christine Rash-Foanio; Kelly Schmidt; Neeha Shrestha; Allen J Vaida; Michael J Gaunt Journal: BMJ Qual Saf Date: 2019-08-07 Impact factor: 7.035