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

Abstract

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.

Medicine Identification New Database (MIND): A quick, simple and accurate tool for the identification of unlabelled medication in hospital pharmacies

“…Recent studies have reported that incorrect identification of look-alike tablets or pills figures prominently amongst fears surrounding medication errors, 10 while "soundalike look-alike" medication confusions harm as many as a quarter of a million of Americans annually. 11 The development of MIND into a smartphone application coupled with a portable spectrometer may be useful for a variety of health professionals wishing to identify medicines. The content of the MIND databases requires continuous updating to include new medicines, and to modify existing medicines for any changes of the solid oral form.…”

Development and exploratory analysis of software to detect look-alike, sound-alike medicine names

“…More recent research into predictors of confusable medicine pairs by Her and Toh confirmed that similarity in product characteristics, particularly between medicines from the same manufacturer, are significant. 3 Our premise is that these factors may be considered by clinical experts alongside practice-related risks such as the proximity of storage of the LASA medicines and their use in high-pressure clinical environments. As such, the computational outputs require interpretation in relation to the clinical setting and the respective presentations of the confused medicines.…”

“…Risks associated with confusable medicine names have been recognized in the literature [1][2][3][4] and the emergence of quality and safety initiatives in the past decade. Medicine names that look alike and/or sound alike (LASA) require vigilance during their prescribing, dispensing, administration to patients and monitoring, 1 and across manual and electronic processes.…”

“…[6][7][8][9] However, it is evident from clinical incident reports and characterization of risks that name approval processes are insufficient to prevent LASA errors. 2,3,10 Numerous safety initiatives, generally based on drawing attention to medicines at risk of being confused, have been introduced in clinical practice to reduce erroneous substitution of a LASA medicine. 4,5 One such initiative is the 2011 National Tall Man Lettering List ('the 2011 List') published by the Australian Commission on Safety and Quality in Health Care, and informed by Australian and international reports of errors and near misses involving LASA medicines.…”