Medication Errors Percipitated by Sound-Alike, Look-Alike Drugs

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In November of 2007 Dennis Quaid and his wife, Kimberly learned that their newborn twins were given a potentially lethal overdose of the drug Heparin. On accident. Upon further investigation it was learned that the error was precipitated by two different doses of Heparin being labeled similarly – leading the health care worker to administer the wrong dosage. The Quaids are not alone.

The 8th annual MEDMARX data report was released Tuesday by U.S. Pharmacopeia (USP) revealing a list of 1,400 commonly used drugs that were given in error due to their sound-alike or look-alike names. The findings report that 1.4% of the errors were associated with patient harm – seven of those may have been involved in the death of the patient.

USP (www.usp.org) a private, independent research-based public health organization tasked with setting public-standards for all prescription and over-the-counter meds and dietary supplements as well as other health care products distributed in the United States. Their standards of practice are utilized in 130 countries world wide. In response to increasing med errors USP developed MEDMARX in 1998. MEDMARX provides an anonymous avenue for health care providers to report medication errors. MEDMARX analyzes and tracks those errors, processing 1.2 million drug errors from over 870 health care agencies across the United States since its birth.

Upon release of the findings USP has urged an “indication for use” (such as nausea, heart burn, blood pressure) label for all medications. Such a label would provide another level of confidence that the wrong drug would not be administered on confusion of name or packaging. The MEDMARX report has established a list of 3,170 pairs of names that look-alike or sound-alike, including the 1,470 drugs that were involved in some sort of medication error.

The chance of eradicating medication administration errors is slim. Health care givers are human, and mistakes will be made. Still, it’s important to be sure that our system has the safest process for administering medications to patients. Keep your practice safe by following this inconclusive list of guidelines.

• Every drug administered should be checked no less than three times. The medication record should be cross checked with the doctor’s orders on every shift. Doses of narcotics and insulin should always be checked by an additional qualified drug administrator. Hospitals are working short staffed often, leaving health care workers frenzied and overworked. Never allow that fact to be a reason to take short cuts on drug administration.

• Alert your pharmacy if you notice a potential for errors, such as two labels that are similar and could be easily mistaken for each other. When new or unfamiliar drugs land on your floor, investigate them. Learn how they are packaged, side effects, actions and interactions. Know your drugs.

• Be familiar with MEDMARX and read new information as it is released pertaining to safe administration of medication. Always be aware.

• Encourage your patients to always ask for clarification on what drugs they are taking. My sister, a breast cancer survivor, was nearly given the wrong chemotherapy cocktail. She was saved by asking what medication the nurse was giving and cross-referencing it to what she had personally recorded as her correct medication. Teach them to be aware of what medications they are on and why. Have them ask questions and clarify information when they’re unsure. Encourage astute patients and care givers.
Learn more about medication errors at www.fda.org