8/16/2019 Error reduction strategies for look alike sound alike medications.pdf

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Error Reduction Strategies forLook-Alike Sound-Alike Medications

For More Information Contact

May Adra, PharmD, Medication Safety Coordinator,

madra@bidmc.harvard.edu 

Interventions  Identify LASA drugs when a new drug is considered for addition to the formulary.  Create a dedicated pharmacy group to manage look-alike sound-alike drugs.  Purchasing pharmacy group calls out the acquiring of any LASA products as a result

of a drug shortage.

  Pharmacy supervisors evaluate their respective areas for the presence of any LASAdrugs.

  Error reduction strategies such as use of tall-man lettering or bar-coding areimplemented.

  Information on LASA drugs and implemented error reduction strategies arecommunicated to staff.

  Evaluate medication stocking, labeling, ordering, and dispensing processes foradditional potential error reduction steps when medication error may occur  

Lessons Learned  Certain medication storage areas remain susceptible to LASA errors due to the lack

of bar-coding and scanning.

  Drug shortages continue to pose a challenge to reducing errors with LASA drugs.

Next Steps 

Improve communication to staff members about look-alike sound-alike drugs and

steps implemented to reduce errors.  Expand the use of bar-coding and scanning technology

ProblemSimilarities in drug names or in drug packaging often lead to medication errors.

  The Institute for Safe Medication Practices (ISMP) and The Joint Commissionrecognize the need to identify and reduce errors with LASA medications.

  BIDMC has a list of LASA medications and established error reductionstrategies; however errors with LASA medications continue to occur.

   An unprecedented increase in the number of drug shortages has led to adecrease in number of available options for drug packages and, to asubsequent increase in the purchasing of LASA products.

 Aim/Goal  To decrease errors caused by look-alike sound-alike drug names or packages by:

  Recognizing areas of vulnerability in the medication use process  Establishing a better communication plan on LASA medications  Identifying effective error reductions strategies

TeamMay Adra, PharmD; Denise Arena, RPh; Jean Beach; Jenny Chiu;Holly Creveling, RPh; Margaret Stephan, RPh; David Mangan, PharmD;Yu Choi, RPh