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July 2011
Vol. 2
Medication Safety Bulletin
Next Issue:
November 2011
Look-alike & Sound-alike (LASA) Medication Names
I
Announcement :
t is not surprising that many drug names
sound and look alike. Frontline colleagues
may easily be confused with unclear handwritten prescriptions because of the
similarity in name or appearance. It is one of
the most common causes of medication error
and is of concern worldwide.
- In order to enrich the
educational content
related to medication
safety, the sharing on
medication incidents
and consolidated
statistics will be
published in HA Risk
Alert (HARA).
Contributing factors to confusion:
- This bulletin will be
published half-yearly in
November and May from
next issue onwards.
Illegible handwriting
●
Incomplete knowledge of drug names
●
Newly available products
●
Similar packaging or labeling
●
Similar clinical use
Similar strengths, dosage
forms, frequency of
administration
●
“Tall man” lettering is a method for
differentiating the unique letter characters
of similar drug names known to have been
confused with one another. Highlighting a
unique portion of a drug name with upper
case letters can draw attention to the
dissimilarities between look-alike drug
names, making them less prone to mix-up.
In US, several studies
have shown that the
utilization of tall
man
lettering
is
effective in reducing
errors caused by
look-alike names.
Standardization of TALL man lettering for LASA names
Inside this issue:
Sharing of good practices to manage LASA
drugs
●
Use of TALL man lettering for look-alike
drug names:
P.2
Sharing of potential risk P.3
found in HA hospitals Similar packing of
500ml dextrose IV infusion bottles: D5 vs D50
Test your knowledge abbreviations used in
prescription
P.3
Sharing of globally
reported medication
errors - FDA alert on
confusion between
Risperidone
(Risperdal® ) &
Ropinirole (Requip® )
P.4
“High Alert Medications” to replace “High
Risk Medications”
P.4
Answers to the test
P.4
A
s one of the difficulties with the use of
tall man letters include inconsistent
application in hospitals and lack of
standardization regarding which name pairs
to include as well as which letters to be in
uppercase, the HA Medication Safety
Committee (MSC) has compiled and standardized 11 sets of generic drug names. This
list has made reference to both the overseas
recommendations and locally reported mixup drug names. Colleagues are advised to
standardize and apply the TALL man letters
to the labeling of drug storage locations such
as drug shelves at pharmacy and drug cupboards in wards. The tall man parts are
preferably in bold and colored letters for
more prominent illustration.
MSC will review and update the list annually.
Colleagues are recommended to be vigilant
on any potential risky pairs and feedback to
MSC via cluster
representatives for
consideration.
Page 2
Medication Safety Bulletin
Sharing of good practices to manage LASA drugs
M
SC had been conducting hospital visits to different hospitals since Feb 2009 and the first
round visit of 7 clusters had been completed. During the hospital visits, MSC observed many
good practices undertaken by hospitals to enhance medication safety, some of which are effective
in tackling problems caused by similar drug packing or drug names.
LASA/ Medication Safety Notice Board
- To alert colleagues on LASA drugs and drugs with
appearance changed recently
Prompting of LASA warning in pharmacy system
— CARS (by item endorsement function)
E.g. An alert box of “LASA Warning: amloDIPINE” is
prompted whenever the item code “AMLO01” is
entered into the CARS
Use of TALL man letters when labeling at
pharmacy and in ward
Reminder on drug shelf to check the drug label
Use of “LASA drug” alert labels during dispensing
Separation of drug storage for different strength
products/ LASA drugs
Page 3
Sharing of potential risk found in HA hospitals
- Similar packing of 500ml dextrose IV infusion bottles : D5 vs D50
L
abels of various strengths and volumes of dextrose IV infusion bottles (i.e. D5, D20 and D50) supplied by a
drug company have been changing in phases since May 2010. Subsequent to the change, a number of medication incidents and near misses have been reported in hospitals recently due to mix-up of D5 and D50 preparations.
NEW packing labels — 500ml Dextrose 5% vs 500ml Dextrose 50%
Recommendations:
1.
Avoid keeping both strengths (5% and 50%) with the same volume as ward stock. Review the ward stock list
and consider replacing the 500ml D50 with 20ml D50 if possible.
2.
Separate the storage of similar packing bottles at pharmacy and in ward. Place a warning labels to remind
staff to be vigilant when picking these items.
3.
Educate and alert staff the importance of medication safety related to label design and label change.
Education poster on new product labels provided by the drug company
Test your knowledge - abbreviations used in prescription
Q1: What does “mane” stand for?
Q2: Can you differentiate among “qid, qod, qds and qd”?
Q3: Which of the above abbreviation(s) is(are) not allowed to be used in HA
(Answers are at the back of this page)
Page 4
Medication Safety Bulletin
Sharing of globally reported medication errors
- FDA alert on confusion between Risperidone (Risperdal® ) & Ropinirole (Requip® )
R
ecently, FDA evaluated the medication errors relating to
the confusion between risperidone (Risperdal ® ) and ropinirole (Requip® ) obtained from their Adverse Event
Reporting
System database. In some cases, patients who took the wrong
medication resulted in adverse events and were hospitalized. Adverse events resulting from administering wrong medication included confusion, lethargy, ataxia, hallucinations, tiredness, dizziness, tingling, numbness and altered mental status.
Possible factors to the confusion:
1.
Similarities of both the brand and generic names
2.
Illegible handwriting on prescription
3.
Overlapping product characteristics, such as the drug strengths, dosage forms, and dosing intervals
4.
Similarities of the container labels and carton packaging (for generic products by the same manufacturer)
Recommendations:
1.
Prescribers to write/ print the drug name clearly on the prescription/ MAR
2.
Pharmacists to confirm/ clarify the drug name with the prescribers if the prescription is not legible
3.
Pharmacy staff to physically separate the stocks of these two drugs on the shelf
4.
Pharmacists to counsel patients about the prescribed medication, make sure patient understands the
purpose of taking the medication to avoid prescribing/ dispensing incorrect medication
“High Alert Medications” to replace “High Risk Medications”
H
igh risk medications are medications that have the highest risk of causing injury when misused. Errors with
these products are not necessarily more common, but the consequences are clearly more devastating.
In order to align with the term used in overseas countries, the term “High Alert Medications” would be used in the
future communications instead of the term “High Risk Medications”.
1. Concentrated
2. Cytotoxic
3. Drugs commonly associated with
electrolytes
chemotherapy
drug allergies e.g. Penicillin, aspirin,
9. Narcotics/
NSAIDs
& inotropes
High “Alert” Medications
opioids
8. Insulins
4. Vasopressors
7.
Oral
hypoglycaemics
5. Anticoagulants
including
6. Neuromuscular
heparin
blocking agents
Q3: “qod” and “qd” are not allowed to be used in HA (refer to HA “Do Not Use” list)
Answers
daily
qd
Every other day
qod
Four times a day
Q2: qid/ qds
In the morning
Q1: mane
Abbreviation
Intended meaning
qod or qds
Spell out “daily”
Spell out “every other day”
q.d. (daily)
Use qid instead of qds
qds can be mistaken as qd
Tomorrow morning
Possible confusion
This Bulletin is prepared by the Chief Pharmacist’s Office, HAHO
Recommendations