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Patient Safety Tip of the Week
October 31, 2023
More on
Look-Alike Sound-Alike (LASA) Drug Errors
In discussing our recent column on the dangers of copy/paste
(August 29, 2023 Patient Safety Tip of the Week The Perils of Copy and Paste),
a colleague noted it had taken him almost 10 years to get his medical record
corrected after it had erroneously showed him to be taking Celexa rather than
the Celebrex he was actually taking.
That, of course, gets us back to the longstanding issue of
LASA (look-alike, sound-alike) drug errors. Timely is an article on Medscape (Doheny 2023) about LASA
drugs, triggered by ISMPs recent addition of 80 new drug pairs to its list of
confused names (ISMP 2023a).
That list now includes about 528 drug pairs, the lengthy list partly due to
each pair being listed twice, so readers can cross reference. Its not
surprising that the list is growing, given that the FDA has approved, on
average, 43 new drugs each year since 2013.
Doheny lists a few examples of the new additions but then
discusses tools to reduce LASA errors, including:
·
Tall-man lettering (see our prior columns listed
below and the updated ISMP and FDA
Tall-man letter lists)
·
Electronic prescribing
·
Using both brand and generic names on labels and
prescriptions
·
Including the indication on the
order/prescription (see our many prior columns on this issue)
·
Smart formulary additions (assessing for
potential LASA issues when adding a new drug to your formulary)
·
Barcode scanning
·
Consumer education
One change in the last few years aimed at reducing LASA
errors has been requiring input of a minimum of five letters when searching for
a medication electronically. In 2019 ISMP, in its Guidelines for the Safe Use
of Automated Dispensing Cabinets, recommended the entry of a minimum
of five characters of a drug name during searches in ADCs. (Note that
ISMPs Guidelines for Safe
Electronic Communication of Medication Information also include
that requirement for medication searches on other forms of electronic
communication.) That is an improvement but, even then, there are challenges.
ISMP saw reports where even entry of 5 letters was associated with errors (ISMP 2021) and
summarized the circumstances in which these errors were occurring. Despite
these limitations and challenges, ISMP still recommends using at least five
characters when conducting drug name searches. In that 2021 article ISMP has
recommendations for dealing with drug names with the same beginning characters
beyond five letters and some other problematic issues.
Doheny notes that the FDA also offers the phonetic and
orthographic computer analysis (POCA)
program, a software tool that employs an advanced algorithm to evaluate
similarities between two drug names. The data sources are updated regularly as
new drugs are approved.
Make sure youve updated your confusing names list and Tall-man lettering list and are using the many tools listed
above to reduce the risk of LASA errors.
Some of our other
columns on medication errors involving LASA drug pairs:
May 20, 2014 Ophthalmology: Blue Dye Mixup
September 2014 Another Blue Dye Eye Mixup
May 2016 Name
Confusion in the Pharmacy
January 1, 2019 More
on Automated Dispensing Cabinet (ADC) Safety
February 12, 2019 From
Tragedy to Travesty of Justice
August 15, 2023 Problems with Newer Diabetes
Drugs
See our previous columns on tall man lettering:
·
December 2010 ISMP
Updates Tall Man Lettering List
·
December 2015 TALLman
Lettering: Does It Work?
·
July 2016 ISMP
Updates TALLman Lettering List
·
October 2016 More
on Tallman Lettering and LASA Drug Pairs
·
March 2023 ISMP
Updates Tall Man Letter List
Some of our other
columns on including indication for medication orders:
March 23, 2010 ISMP
Guidelines for Standard Order Sets
December 18, 2018 Great
Recommendations for e-Prescribing
August 2019 Including Indications for
Medications: We Are Failing
March 1, 2022 Including the Indication on
Prescriptions
May 24, 2022 Requiring Indication for
Antibiotic Prescribing
March 7, 2023 One of Our Pet Peeves: Lack of
Indication on Medications
References:
Doheny K. Drug Name Confusion: More Than 80 New Drug Pairs
Added to the List. Medscape Medical News 2023; August 08, 2023
https://www.medscape.com/viewarticle/995258
Institute for Safe Medication Practices (ISMP). ISMP List of
Confused Drug Names. ISMP 2023; July 26, 2023
https://www.ismp.org/recommendations/confused-drug-names-list
FDA (US Food and Drug Administration). Phonetic and
Orthographic Computer Analysis (POCA) Program. FDA 2012
Institute for Safe Medication Practices (ISMP). Look-Alike
Drug Names with Recommended Tall Man (Mixed Case) Letters. ISMP 2023; January
26, 2023
https://www.ismp.org/recommendations/tall-man-letters-list
ISMP (Institute for Safe Medication Practices). Guidelines
for the Safe Use of Automated Dispensing Cabinets. ISMP 2019; February 7, 2019
https://www.ismp.org/resources/guidelines-safe-use-automated-dispensing-cabinets
ISMP (Institute for Safe Medication Practices). Guidelines
for Safe Electronic Communication of Medication Information. ISMP 2019; January
16, 2019
https://www.ismp.org/resources/guidelines-safe-electronic-communication-medication-information
ISMP (Institute for Safe Medication Practices). Challenges
with Requiring Five Characters During ADC Drug Searches Via Override. ISMP
Medication Safety Alert! Acute Care Edition 2021; October 21, 2021
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