Look‐alikes, sound‐alikes: Three cases of insidious medication errors

Abstract

Medication errors represent a threat to patient safety 1 and comprise administration of a drug to the wrong patient, choice of the wrong route of administration, application of a drug at the wrong time, and administration of the wrong drug. 2 Administration of the wrong drug may originate from confusion of similarly looking and/or sounding drug names, for example, hydroxyzine and hydralazine. 3 In this article, we investigate three cases in which confusion of look-alike/sound-alike (LASA) drug names triggered medication errors with quite distinct outcomes. 2 | CASE 1 An 80-year-old woman (referred to as patient 1) was admitted to the gerontopsychiatric ward of our university hospital via the emergency room due to the acute exacerbation of a recurrent major depressive disorder with psychotic symptoms. Somatic comorbidities comprised atrial fibrillation, arterial hypertension (with recurrent hypertensive crises in the past), peripheral arterial occlusive disease, third-degree atrioventricular block (implantation of a cardiac pacemaker had occurred 7 months previously), and type 2 diabetes mellitus. The patient's medication consisted of clopidogrel, ramipril, amlodipine, metoprolol extended release (ER), urapidil ER, metformin, simvastatin, melperone, and insulin glargine, and was copied into the paper-based hospital medication chart by the ward physician in a clearly legible manner (Figure 1). Nevertheless, 75 mg of clozapine were dispensed instead of 75 mg of clopidogrel. Soon after the erroneous intake of clozapine instead of clopidogrel, patient 1 was found sitting unconsciously in a chair on the ward floor. The ward physician noted a score of

Nurses' perspectives on medication errors and prevention strategies in residential aged care facilities through a national survey

“…Similarly, a national survey study conducted in selected hospitals in Saudi Arabia, identified most medication errors occurred from confusion between names and colour of packages and varying labels of LASA medications (Aljadhey et al, 2013). Various incidents of errors have been reported in hospitals, where packing and labelling of LASA medications, and spelling directly led to dispensing and administration errors (Heck et al, 2020). Prescription errors also occur due to the similarities of medications in the electronic medical records.…”

Análise das prescrições de antimicrobianos para pacientes hematológicos em relação ao protocolo de medicação segura em um hospital de ensino

“…Revista Brasileira de Farmácia Hospitalar e Serviços de Saúde pISSN: 2179-5924 dos riscos no processo de prescrição foi feito em um hospital da Itália e mostrou uma série de modos de falhas em potencial com relação ao sistema de distribuição de medicamentos com nomes semelhantes 21 . Em um relato de caso de EM com nomes semelhantes, houve a confusão entre o medicamento prescrito "meronem" com outro medicamento com nome parecido "melperon" que poderia ser fatal para ao paciente por overdose 22 .…”

Proposal of a Tall Man Letter list for German-speaking countries

“…Administration of the false drug may result from the confusion of two similarly looking and/or sounding drug names, the socalled look-alike/sound-alike (LASA) medications [3]. We have previously reported on three cases of insidious LASA medication errors that occurred at our university hospital [4].…”

“…Since Hannover Medical School is obliged to a policy of transparent error management, the published cases [4] have been thoroughly investigated and potential countermeasures have been discussed to avoid similar scenarios in the future. Tall Man Lettering (TML) describes a concept of partial capitalisation of drug names that aims at better distinguishability, thereby reducing the risk of confusion of LASA medications [3,5].…”

“…In the aftermath of the disturbing cases of LASA medication errors that occurred at our institution [ 4 ], an interdisciplinary expert panel comprised of representatives from clinical pharmacology, psychiatry, and general medicine convened and decided to create a TML list in German. To this end, existing TML lists [ 6 – 8 ] were screened and appropriate agents were selected based on their availability and frequency of use in Germany.…”