Dispensing errors from look-alike drug trade names

Abstract

ObjectivesTo improve patient safety, we investigated near-miss dispensing errors in our hospital and evaluated the effectiveness of specific preventive strategies.MethodsThe incidence and type of near-miss dispensing errors in a single hospital in Taiwan were identified in 2013. The causes of dispensing errors were analysed by consensus of an expert panel comprising a senior pharmacist on duty, a group leader in the pharmacy and an author. Because alphabetical trade names were routinely used in our pharmacy, they were used for similarity analysis. Trigram-2b and normalised edit distance (NED) were used to calculate orthographic similarity and distance measure, respectively. The correlation between drug-name confusion and dispensing errors was then studied. Preventive strategies, including the introduction of tall man letters, were completed at the end of 2013, and error data were then recollected in 2014. Differences between before and after the interventions were examined by t-test.ResultsBefore the intervention, look-alike alphabetical names were the main cause of dispensing wrong medicine (134/202, 66.3%). The frequency of near-miss dispensing errors correlated significantly with drug-name similarity (p<0.01). After implementation of preventive strategies, dispensing errors due to drug-name confusion were reduced significantly (77/140, 55.0%, p=0.004).ConclusionsThe frequency of near-miss drug dispensing errors correlated with greater similarity or lower NED scores, and dispensing errors related to drug-name confusion were significantly reduced by our interventions. However, other dispensing errors might need to be investigated in order to prevent them.

Fatores associados a erros de dispensação de medicamentos: contribuição à melhoria de sistemas de medicação

“…Os fatores mais comuns encontrados em outras pesquisas foram: alta carga de trabalho, baixo número de funcionários, confusão com nomes e sons parecidos/similares, falta de conhecimento/experiência da equipe da farmácia, pressa e interrupções/distrações. Entretanto, estes fatores foram apontados a partir de relatos subjetivos, entrevistas e/ou formulários de notificação de incidentes [13][14][15][16][17][18] .…”

Interventions to decrease the incidence of dispensing errors in hospital pharmacy: a systematic review and meta‐analysis

“…Six of the included studies utilised a pre and post-intervention methodology with prospective observations, [24][25][26][30][31][32] four were parallel arm prospective observational studies 22,[27][28][29] and one was a multi-phase prospective observational study. 23 The data collection periods ranged from 6 days to 1 year.…”

“…The majority of studies used a research pharmacist observer who identified dispensing errors independent to the dispensing process, 22,[24][25][26][27]30 while others incorporated the identification and documentation of dispensing errors into the final verification stage of the dispensing process. 23,24,29,31,32 In all but one study, those evaluating the presence of dispensing errors were not blinded to the study allocation of the medication orders or prescriptions being assessed. One study utilised a blinded research pharmacist to review dispensed items after completion of the final verification by pharmacy staff.…”

A drug identification model developed using deep learning technologies: experience of a medical center in Taiwan

“…Unfortunately, major problems remain in drug identification: many drugs look alike; drugs are relatively small in size; and a large number of drugs need to be identified. Existing identification solutions still have their limitations [5][6][7].…”