Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors

Seoane‐Vazquez, Enrique; Rodríguez-Monguió, Rosa; Al‐Qahtani, Saleh M.; Schiff, Gordon D.

doi:10.1080/14740338.2017.1358361

Cited by 12 publications

(9 citation statements)

References 33 publications

(36 reference statements)

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“…[3][4][5]21,[24][25][26][27] To our knowledge, only 2 other studies have indirectly evaluated the associations of matching medication product attributes on SALA confusion. 16,17 Both studies explored the associations of SALA confusion with generic name, therapeutic class, health problem, or medication indication. They found that a substantial proportion of SALA medication pairs shared the same indications or belonged to the same therapeutic class.…”

Section: Discussionmentioning

confidence: 99%

“…Preliminary results of this study were presented at the American Pharmacist Association's Annual Meeting (March [16][17][18][19]2018; Nashville, TN) in the form of a poster presentation.…”

Section: Authors' Notementioning

confidence: 99%

“…Two previous studies indirectly evaluated the association between matching medication product attributes and their propensity for SALA confusion. 16,17 Both studies found that a high proportion of SALA medication pairs had the same indications or belonged to the same therapeutic class. However, neither study included a control group necessary to quantify the strength of the associations between specific product attributes and SALA confusion.…”

Section: Introductionmentioning

confidence: 99%

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Sound-Alike Look-Alike Confusion and Matching Medication Product Attributes: Simulated Case-Control Studies

Her

Toh

2019

Ann Pharmacother

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Background: Sound-alike look-alike (SALA) medication confusions harm as many as 250 000 Americans annually. Most preventive strategies focus on medication name similarities. Objectives: To evaluate the association between matching medication product attributes and SALA confusion. Methods: We simulated 20 000 case-control studies using the Institute for Safe Medication Practices’ List of Confused Drug Names as case pairs and 4 randomly selected control pairs per case pair from the First DataBank MedKnowledge (FDBM) database. We extracted 7 product attributes for each medication from the FDBM database. We used logistic regression models to estimate the associations between matching product attributes and SALA confusion. The models included a series of univariate (unadjusted) models, a model that adjusted for all product attributes, and a model that further adjusted for medication name similarity measures. Results: Medications with a matching product attribute had increased odds of SALA confusion in the univariate analyses (odds ratio [OR] = 4.2 to 55.5). When we simultaneously adjusted for all attributes, the associations of matching package unit, package unit size, formulation, strength, therapeutic class, and manufacturer with SALA confusion were attenuated but remained elevated (OR = 1.5 to 26.5), whereas the direction of association between matching route and SALA confusion reversed (OR = 0.8). These associations persisted on adjustment for medication name similarity measures. Conclusions and Relevance: This study is the first to evaluate the association between matching medication product attributes and SALA confusion with a control group. Having matching product attributes increased the odds of SALA confusion. SALA risk reduction strategies should consider product attributes.

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Section: Discussionmentioning

confidence: 99%

“…Preliminary results of this study were presented at the American Pharmacist Association's Annual Meeting (March [16][17][18][19]2018; Nashville, TN) in the form of a poster presentation.…”

Section: Authors' Notementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Sound-Alike Look-Alike Confusion and Matching Medication Product Attributes: Simulated Case-Control Studies

Her

Toh

2019

Ann Pharmacother

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“…The investigations on medication errors have discovered some critical topics like awareness of confused drugs and control of high-risk drugs. The confused drugs, including look-alike, sound-alike (LASA) name pairs, are a critical group for medication errors 4 . LASA covers medications with visual similarities in physical appearance, packaging, and/or name (in the form of spelling and/or phonetics).…”

Section: Introductionmentioning

confidence: 99%

Be aware of critical drugs in emergency departments: An extreme iatrogenic insulin overdose via subcutaneous and intramuscular routes

Çoşkun

Vural

Eroğlu

et al. 2021

Journal of Emergency Medicine Case Reports

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Introduction: Insulin is a highly used parenteral medication in emergency departments. Although most severe insulin overdoses occur as suicide attempts, medication errors can be the reason. We aimed to highlight the potential medication errors in emergency departments due to the poor control of critical drugs like insulin and the similarities between the brand names of drugs, as we experienced during this case. Case Report:We present a 75-year-old diabetic woman with an extreme insulin overdose. A total of 3000 UI of insulin was administered by subcutaneous and intramuscular routes. She developed typical and atypical episodes of hypoglycemia requiring intravenous dextrose, a high-calorie diet, and glucagon administration. Almost all of the classic side effects of glucagon occurred during her intensive care unit follow-up. She recovered without any sequela or recurrence of hypoglycemia at the end of 5 days of admission. Conclusion:Insulin overdose can be a life-threatening condition by causing hypoglycemia. Albeit rare, insulin overdose can occur as a medication error in hospitals. To prevent such incidents for emergency departments, the medication errors should be objectively laid out, and proactive strategies should be integrated without adversely affecting acute care.

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“…Studying the incidence of and approaches to preventing medication errors has become a subject of growing importance in medical and pharmaceutical sciences [37][38][39][40][41]. It has been shown that the occurrence of inappropriate medication use can be linked not only to name confusion [42,43] but also, most notably, to labelling and packaging confusion [44][45][46]. Specifically, past research offers insights into the mechanisms of how labelling and final packaging influence the ability to accurately recognize medicines [25,47,48].…”

Section: Introductionmentioning

confidence: 99%

How to prevent medication errors: a multidimensional scaling study to investigate the distinguishability between self-injection platform device variants

Schneider

Kolrep²,

Jordi

et al. 2019

Expert Opinion on Drug Delivery

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Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors

Abstract: Including the FDA-approved indication in the drug prescription may be used to differentiate LASA drug pairs and thus, prevent wrong drug medication errors.

Cited by 12 publications

References 33 publications

Sound-Alike Look-Alike Confusion and Matching Medication Product Attributes: Simulated Case-Control Studies

Sound-Alike Look-Alike Confusion and Matching Medication Product Attributes: Simulated Case-Control Studies

Be aware of critical drugs in emergency departments: An extreme iatrogenic insulin overdose via subcutaneous and intramuscular routes

How to prevent medication errors: a multidimensional scaling study to investigate the distinguishability between self-injection platform device variants

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