Magazine article Drug Topics

Look-Alike/sound-Alike Errors Get More Attention

Magazine article Drug Topics

Look-Alike/sound-Alike Errors Get More Attention

Article excerpt

In the community setting, the pharmacist is the last step between patient and pill. Pharmacists must often multitask as they fill a prescription, so it is not surprising that an error may occur. While various factors may contribute to an error, many mistakes result simply from the confusion of drugs with similar names.

According to the Institute for Safe Medication Practices (ISMP), "Handwritten prescriptions combined with look-alike drug names are among the most risky conditions associated with medication use. Running closely behind is the combination of verbal orders and sound-alike drug names." This assertion is supported by reports submitted to the Medication Error Reporting Program (MERP), operated cooperatively by the ISMP and U.S. Pharmacopeia (USP).

Some 26,000 look-alike/sound-alike (LASA) errors were reported to MERP from 2003 to 2006 by professionals in various healthcare settings. These reports contained 1,470 unique drug names, including those of the top 10 drugs sold by volume in 2008. MERP estimates that one of every four medication errors stems from LASAs. In addition, it calculates that in one of every three cases in which the wrong drug was dispensed, the error could be linked to LASA mistakes.

These statistics are astonishing in light of the fact that the Food and Drug Administration (FDA) rejects a third of all proposed drug names during the application process because of the potential for confusion. In addition to the FDA's efforts to prevent IASA drug names from entering the marketplace, most major pharmaceutical companies hire safety testing companies to evaluate risks associated with potential trademarks (brand names) before launching new drugs. Unfortunately, the ISMP says, many of the smaller pharmaceutical and biotech companies have not yet adopted this practice.

Trademark names are not the only drug names involved in LASA errors. Generic names also pose a problem. However, since these products have been on the market for many years, it is doubtful that generic manufacturers will consider changing names of drug products involved in IASA errors.

Impact on pharmacies

Pharmacies are seeking ways to deal with the LASA challenge. About 22,000 pharmacies are participating in a RelayHealth initiative to reduce such errors. At the point of dispensing, as claims are en route to payers, submitted claims are examined in real-time for possible LASA errors.

The impact on dispensing errors is apparent. Over the past 12 months, pharmacists resubmitted 10,000 prescriptions for a different drug, a different dosage, or a different formulation of the same drug after being alerted that the prescription they were processing might contain a LASA error. …

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