Look-alike/sound-alike medication errors: An in-depth examination through a hospital case study
Main Article Content
Keywords
look-alike sound-alike (LASA), medication error, hospital, Thailand
Abstract
Background: Look-alike/sound-alike (LASA) drugs substantially contribute to global healthcare challenges and patient harm, necessitating a comprehensive understanding of LASA medication errors. Objective: The current study explored the prevalence and characteristics of medication errors related to LASA in a 200-bed general hospital. Methods: A mixed-methods approach was employed. The quantitative component analyzed the LASA drug error data using the hospital database. For the qualitative component, in-depth interviews with pharmacists and pharmacy staff were undertaken to gain insights into stakeholder perceptions and management of LASA-related issues. Results: Quantitative analysis highlighted three types of LASA medication errors: confusion due to similar drug names, appearance, and packaging. Drug name confusion accounted for most errors (64.62%), demonstrating the considerable risk associated with similar medication names. Packaging confusion accounted for 24.61% of errors, indicating the importance of a unique packaging design. Overall, 10.77% of errors were attributed to similar appearance, indicating that the visual resemblance of medications played a considerable role in LASA errors. Forty-six LASA drug pairs were identified, the most frequent being simvastatin 10 mg and simvastatin 20 mg. The errors were divided into two categories: Category A, with two pairs related to name and packaging similarities, and Category B, with 44 pairs involving all types of similarities. The differentiation between these categories underscores the complex nature of LASA errors. Semi-structured interviews revealed that anticipatory errors often occurred during busy periods, which could result in crucial details, such as drug strengths, being overlooked. Proposed solutions for reducing LASA errors included implementing Tall Man lettering, developing movable LASA signage, and improving workforce allocation. Root-cause analysis identified several factors, including drug similarities and staffing issues, as notable contributors to LASA errors, highlighting the need for a multipronged approach. Conclusion: LASA medication errors, particularly those attributed to drug name similarities, pose a considerable risk and persist despite existing safeguards. Implementing tailored strategies, such as Tall Man letters, movable LASA signage, and careful management of high-risk medication pairs, could aid in addressing these issues.
References
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7. Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc (Wash). 2003;43(2):191-200. https://doi.org/10.1331/108658003321480731
8. Bryan R, Aronson JK, Williams AJ, et al. A systematic literature review of LASA error interventions. Br J Clin Pharmacol. 2021;87(2):336-351. https://doi.org/10.1111/bcp.14644
9. Tariq RA, Vashisht R, Sinha A, et al. Medication Dispensing Errors And Prevention. StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. http://www.ncbi.nlm.nih.gov/books/nbk519065/
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13. Larmené-Beld KHM, Alting EK, Taxis K. A systematic literature review on strategies to avoid look-alike errors of labels. Eur J Clin Pharmacol. 2018;74(8):985-993. https://doi.org/10.1007/s00228-018-2471-z
14. Ostini R, Roughead EE, Kirkpatrick CM, et al. Quality Use of Medicines--medication safety issues in naming; look-alike, soundalike medicine names. Int J Pharm Pract. 2012;20(6):349-357. https://doi.org/10.1111/j.2042-7174.2012.00210.x
15. Bryan R, Aronson JK, Williams A, et al. The problem of look-alike, sound-alike name errors: Drivers and solutions. Br J Clin Pharmacol. 2021;87(2):386-394. https://doi.org/10.1111/bcp.14285
16. Salhotra R, Tyagi A. Medication errors: They continue. J Anaesthesiol Clin Pharmacol, 2019;35(1):1-2.
17. World Health Organization. Towards eliminating avoidable harm in health care. Global patient safety action plan. 2021;2030.
18. Chumchit C, Amrumpai Y, Treesak C. Recognition on medication safety and look-alike/sound-alike medication problems in Thai public hospitals. Silpakorn U Science & Tech J. 2015;9(2):40-51.
19. Filik R, Price J, Darker I, et al. The influence of tall man lettering on drug name confusion: a laboratory-based investigation in the UK using younger and older adults and healthcare practitioners. Drug safety. 2010;33:677-687. https://doi. org/10.2165/11532360-000000000-00000
20. Cheng CM, Salazar A, Amato MG, et al. Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs. J Am Med Inform Assoc. 2018;25(7):872-884. https://doi.org/10.1093/jamia/ocy043
21. Billstein-Leber M, Carrillo CJD, Cassano AT, et al. ASHP Guidelines on Preventing Medication Errors in Hospitals. American Journal of Health-System Pharmacy.2018;75(19):1493-1517. https://doi.org/10.2146/ajhp170811
22. Lambert BL, Galanter W, Liu KL, et al. Automated detection of wrong-drug prescribing errors. BMJ Qual Saf. 2019;28(11):908- 915. https://doi.org/10.1136/bmjqs-2019-009420
23. Galanter WL, Bryson ML, Falck S, et al. Indication Alerts Intercept Drug Name Confusion Errors during Computerized Entry of Medication Orders. PLOS ONE. 2014;9(7):e101977. https://doi.org/10.1371/journal.pone.0101977
24. Schwappach DLB, Yvonne P, Katja T. Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences. BMJ Open. 2016;6(6):e011394. https://doi.org/10.1136/bmjopen-2016-011394
25. Alyami MH, Naser AY, Alswar HS, et al. Medication errors in Najran, Saudi Arabia: Reporting, responsibility, and characteristics: A cross-sectional study. Saudi Pharm J. 2022;30(4):329-336. https://doi.org/10.1016/j.jsps.2022.02.005
26. Grissinger M. Guidelines for standard order sets. P t, 2014;39(1):10-50. http://www.ncbi.nlm.nih.gov/pmc/articles/ pmc3956384/
27. Dhawan I, Tewari A, Sehgal S, et al. Medication errors in anesthesia: unacceptable or unavoidable?. Braz J Anesthesiol. 2017;67(2):184-192. https://doi.org/10.1016/j.bjane.2015.09.006
28. Cohen MR, Smetzer JL. ISMP Medication Error Report Analysis. Hospital Pharmacy. 2018;53(4):217-219. https://doi. org/10.1177/0018578717715346
29. Cohen MR, Smetzer JL. No Unlabeled Containers Anywhere, Ever! Where Did this Come From?. Hospital Pharmacy. 2015;50(3):185-188. https://doi.org/10.1310/hpj5003-185
30. Cohen MR. Maalox Brand Name Extension Causes Confusion Near Sight/Sound Dead Hit! Omacor–Amicar Look-alike Tylenol Packets. Hospital Pharmacy. 2006;41(1):13-16.
31. Cohen MR. Another Purpose for “Purpose” Look-Alike Unit-Dose Containers Mixed up Misinterpretation of Sliding-Scale Insulin Dose. Hospital Pharmacy. 2001;36(12):1132-1133.
32. Thirumagal M, Ahamedbari MAR, Samaranayake NR, et al. Pattern of medication errors among inpatients in a resource-limited hospital setting. Postgrad Med J. 2017;93(1105):686-690. https://doi.org/10.1136/postgradmedj-2017-134848
33. Limpanyalert P. (2017). 2P Safety patient and personnel safety. https://hacc.kku.ac.th/haccupload_news/pdftitle/ Tue24545uFpjMOP.pdf. Accessed 02 Jan, 2022.
34. Wongboonnak P. Look-alike sound-alike drugs situation in Thailand. HCU Journal of Health Science. 2018;22:205-216.
35. Wongboonnak P. Resolving the Problems on Look-Alike Sound-Alike Drugs at the System Level. Thai Journal of Pharmacy Practice. 2017;9(1):251-258.
36. Chanakit T, Napaporn J, Chiempattanakajohn T, et al. The survey of look alike/sound alike (LASA) drugs available in hospitals in Thailand. Afr J Pharm Pharmacol. 2013;7(6):227-239.
37. Stewart D, Thomas B, MacLure K, et al. Perspectives of healthcare professionals in Qatar on causes of medication errors: A mixed methods study of safety culture. PLoS One. 2018;13(9):e0204801. https://doi.org/10.1371/journal.pone.0204801
38. Guchelaar HJ, Colen HB, Kalmeijer MD, et al. Medication errors: hospital pharmacist perspective. Drugs. 2005;65(13):1735- 1746. https://doi.org/10.2165/00003495-200565130-00001
39. Constantinou CS, Georgiou M, Perdikogianni M. A comparative method for themes saturation (CoMeTS) in qualitative interviews. Qualitative research. 2017;17(5):571-588. https://doi.org/10.1002/jgc4.1399
40. Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Social Science & Medicine. 2022;292:114523. https://doi.org/10.1016/j.socscimed.2021.114523
41. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893-1907. https://doi.org/10.1007/s11135-017-0574-8
42. Azraii AB, Ramli AS, Ismail Z, et al. Validity and reliability of an adapted questionnaire measuring knowledge, awareness and practice regarding familial hypercholesterolaemia among primary care physicians in Malaysia. BMC Cardiovascular Disorders. 2021;21(1):39. https://doi.org/10.1186/s12872-020-01845-y
43. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). (2022). Types of medication errors. https://www.nccmerp.org/types-medication-errors Accessed 11 October, 2022.
44. Dos Santos L, Winkler N, Dos Santos MA, et al. Description of medication errors detected at a drug information centre in Southern Brazil. Pharm Pract (Granada). 2015;13(1):524. https://doi.org/10.18549/pharmpract.2015.01.524
45. Chan HK, Hassali MA, Lim CJ, et al. Improving pediatric liquid medication labeling of the hospital information system in Malaysia: qualitative analysis of pharmacists’ perceptions. Pharm Pract (Granada). 2016;14(2):699. https://doi.org/10.18549/ pharmpract.2016.02.699
46. Treejan K, Jinatongthai P, Moolasarn S, et al. Self-health care behaviors and knowledge of youth living with HIV. J Am Pharm Assoc (2003). 2022;62(4):1249-1259.e1247. https://doi.org/10.1016/j.japh.2022.02.006
47. Filik R, Purdy K, Gale A, et al. Labeling of medicines and patient safety: evaluating methods of reducing drug name confusion. Hum Factors. 2006;48(1):39-47. https://doi.org/10.1518/001872006776412199
48. Filik R, Purdy K, Gale A, et al. Drug name confusion: evaluating the effectiveness of capital (“Tall Man”) letters using eye movement data. Soc Sci Med. 2004;59(12):2597-2601. https://doi.org/10.1016/j.socscimed.2004.04.008
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May 31, 2024
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Look-alike/sound-alike medication errors: An in-depth examination through a hospital case study. Pharm Pract (Granada) [Internet]. 2024 May 31 [cited 2025 Jan. 14];22(2):1-13. Available from: https://www.pharmacypractice.org/index.php/pp/article/view/2959
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How to Cite
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Look-alike/sound-alike medication errors: An in-depth examination through a hospital case study. Pharm Pract (Granada) [Internet]. 2024 May 31 [cited 2025 Jan. 14];22(2):1-13. Available from: https://www.pharmacypractice.org/index.php/pp/article/view/2959