Medication Safety Overview

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Medication Safety

Overview

Focus on Look-alike Sound-alike Medications

Rita Montone, RPh, MBA Operations Manager

Department of Pharmacy

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Medication names and packaging

¾ There are 15,000 brand medication names

alone on the market

¾ “Names” for medications are a common

cause

¾ As of June 2005, more than 399 problematic

sets of confusing medication names

¾ Misunderstanding of medication names

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How are medications named??

z

Each medication has three names

–

Chemical name

z 4-chloro-N-furfuryl-5-sulfamoylanthranilic acid. –

Generic name

z furosemide –

Brand name

z Lasix ® (Hoescht)

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Proprietary Name Concerns:

z May imbed dosing schedule

z Confusion when a suffix represents an

indication for use

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Brand Name Mis-recognition

z Examples

– Dimetapp

– Sudafed vs Sudafed PE – Humibid LA

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Proprietary Name Concerns:

Fanciful Name Extenders

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Effexor® Confusion

z

Drug Generic Name(s)

VENLAFAXINE

HYDROCHLORIDE

Brand Name

Drug Generic Name(s)

VENLAFAXINE HYDROCHLORIDE Brand Name EFFEXOR XR EFFEXOR Strength(s) VENLAFAXINE HYDROCHLORIDE: 75 MG Imprint W EFFEXOR XR75 Strength(s) VENLAFAXINE HYDROCHLORIDE: 75 MG Imprint W 75 704

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Conceptual Reasons for Medication

Errors

Any or all of the following characteristics can contribute to the medication error:

¾ Generic name ¾ Brand name

¾ Dosage and/or strength supplied ¾ Dosage form

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Conceptual Reasons for Medication

Errors (cont.)

¾ Route, frequency ¾ Instructions for use ¾ Storage requirements ¾ Indications

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Medication name confusion

z Generic or brand names sound similar

z May have similar indications

z Medication strengths may be available as

identical formulations

z Storage may be in the same portion of the

alphabet

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14 Stress Care Process es Brand names Dose forms Generic names Doses Routes Communications Labels Symbols Abbreviations Legibility Human factors Storage UBC Packaging Computers Culture Marketing Work condition Fatigue Language Suffixes Combo product Patient Indication Care Setting Preparation Purchasing New / Changed Product Or Process Task Team Nomenclature Dose Regimens Knowledge ERRORS! www.fda.gov/cder/meeting

The Whirlwind of disruptions

Whirlwind of disruptions

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Medication Use System check points

z

Prescribing

z

Dispensing

z

Administration

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Prescribing - Legibility of drug

names

Unasyn or Vancomycin?

Protonix or Protamine?

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Dispensing - / - / - Purchasing

www.ismp.org z

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Look-alike / Carpuject packaging

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Spot the difference?

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High Alert Medications at Bayhealth

Medical Center

z Insulins

(Humulin, Novolin, Humalog, NovoLog, Lantus)

z Heparin (low molecular weight) e.g. Enoxaparin,

z Heparin (unfractionated)

z Lidocaine IV

z Warfarin

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High Alert Medications at Bayhealth

Medical Center

(cont.)

z Propofol

z Moderate sedating agents for children

(e.g. chloral hydrate)

z Total Parenteral Nutrition

z Dextrose (hypertonic -20% or greater)

z Cardioplegic solutions

z Sodium Chloride (hypertonic – greater than 0.9%)

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Bayhealth Pharmacy-Nursing alert

stickers

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Saline

z Normal Saline is 0.9%

(154mEq Sodium Chloride) per liter z Hypertonic Saline is 3%

(500mEq Sodium Chloride) per liter

z 23.4% sodium chloride (concentration 2.5mEq/ml) vial is needed for compounding TPNs as well as specialized saline solutions

– Stocked in Pharmacy – Stocked in Dialysis

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Look Alike – Sound Alike

z Insulin Products

z Heparin ---- Hespan

z Warfarin ---- Avandia ®

z Morphine ---- Morphine

(concentrated) (conventional liquids)

z Hydromorphone ---- Morphine

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Insulin Issues ,

Packaging

z Factors Contributing to Errors

1. Similar Packaging

2. 10-mL vials – same shape

3. Labels carry identical logos printed in the same style and color

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Prescribing - Insulin Issues

(labeling and nomenclature)

Humulin “Log” ordered instead of Humulin-L (Lente). Nurse thought Humalog” was to be given.

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Insulin Issues

(nomenclature)

Similar names:

z Humulin® vs. Humalog®

z Lente® _vs. _Lantus®

z Novolog® _vs. _Novolin®

z Novolog® _vs. _Humalog®

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Handwriting example for:

Hep

arin - Hespan

z HESPAN and Heparin share the characters

"H-E," "P-A," and "N" in the same order

z HESPAN products may be packaged in premixed bags with coloring similar to heparin bags

z Often stored near one another due to their similar spelling.

z Heparin and HESPAN, when loaded into AcuDose, both names appear alphabetically similar as choices on the machine's computer screen.

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Heparin

z Standardize concentrations for intravenous

administration

z Use standardized protocols

z Requires ongoing monitoring; dosage

adjustments

z Pre-mixed bag containing 25,000 units in

250ml D5W

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Recommendations for Improvement

z Written communication

z Medication procedures

z Working environment

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Handwriting example for:

Coumadin ---Avandia

CAUTION!

Poorly handwritten orders for AVANDIA (rosiglitazone), used to treat Type 2 diabetes mellitus,

can look like COUMADIN (warfarin),

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Look Alike – Sound Alike

Morphine ----

Morphine

(concentrated) (conventional)

z Used to treat pain

z Concentrated forms of oral morphine solution

(20mg/ml) have often been confused with the

z The standard concentration of

10mg/5ml or 20mg/5ml

z Dispensing by volume instead of by “mg”

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Look Alike – Sound Alike

Hydromorphone

----

Morphine

z Used to relieve pain

z Based on equi-analgesic dose conversion,

this may represent significant overdosage

z Medication errors may result in episodes of

respiratory arrest due to potency differences between these drugs

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Narcotics and Opiates from Automated

Dispensing Cabinets.

z Do not crush extended-release tablets

z Oral solutions are available in various levels

z Don’t confuse morphine with hydromorphone

z Available as floorstock

z May be removed prior to pharmacist

verification of patient medication order

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Dosage forms:

OxyContin

or Oxycodone immediate

release

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Clonidine ---- Clonazepam

z Catapres (clonidine) – used to treated

hypertension

z Klonopin (clonazepam) – used to treat

seizures

The generic name of clonidine can be confused

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Look Alike-Sound Alike

(cont.)

z Serzone ® ---- Seroquel ®

z Zantac ® ---- Xanax ®

z Taxol ® ---- Taxotere ®

z Cisplatin ---- Carboplatin

z Epinephrine ---- Ephedrine

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Case Study

Serzone®

vs

Seroquel®

z Serzone (nefazodone) for schizophrenia

z Seroquel (quetiapione) for depression

– Propensity for errors include:

z Name

z Dosing interval (both are twice daily)

z Dosage form (both are tablets)

z Dosage strengths ( both as 100mg and 200mg)

z Dosage titration (both incremental and targeted range)

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Zantac® ----

Xanax®

z Zantac (ranitidine) is a histamine H-2

receptor antagonist and is used to treat duodenal ulcers and prevent their return

z Xanax (alprazolam) is used to treat anxiety,

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Look Alike – Sound Alike

Taxol

----

Taxotere

z Both medications used to treat cancer

z Confusion between these two drugs can

result in serious outcomes

z Confusion when ordered as brand names

z Brand / Generic names –

TaxOL (PACLItaxel)

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Cisplatin ----

Carboplatin

z Both medications used to treat cancer

z Confusion between these two drugs can

result in serious outcomes

z Confusion when ordered as brand names

z Brand / Generic names –

Platinol-AQ® (CISplatin) Paraplatin® (CARBOplatin)

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Look Alike – Sound Alike

Epinephrine ----

Ephedrine

z Adrenalin (epinephrine)

– A bronchodilator

– Used in the emergency treatment of allergic reactions – Restore cardiac rhythm in cardiac arrest

z Ephedrine

– A bronchodilator

z TALLman lettering in computer and cabinets:

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Celebrex ® -- Celexa ® -- Cerebyx ®

z Celebrex (celecoxib) – COX-2

anti-inflammatory agent

z Celexa (citalopram) – used to treat

depression

z Cerebyx (fosphenytoin) – used to treat

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Celexa - Celebrex

Celexa 40mg Celexa 20mg

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Technology Update - Bar Coding

z Drugs

– NDC Number

– NDC can be contained in:

z Universal Product Code Number (UPC)

z International Article Number (EAN)

z Global Trade Item Number (GTIN)

– NDC Number - Administered by FDA - Center for Drug Evaluation and

Research (CDER)

z Labeler Code: Manufacturer, repackager or distributor

z Unique number assigned by Labeler for strength, dosage form, and formulation for a particular firm

z Trade Package Size and Type

– Other information such as lot number and expiration date maybe

optionally

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Barcode Technology

z Series of vertical lines and spaces that scanner converts to electrical signal understood by computer

z Used in grocery stores since 1970s

z Can store alpha and numeric and information

z Provides accurate, fast, real-time data collection and entry

z Offers exceptional security

z Minimizes errors associated with manual data entry

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Packaging

z Universal look to unit-dose packaging if often

misleading whether purchased in manufacture unit-dose packaging

“OR”

z Packaged in the hospital pharmacy utilizing

the medi-dose packaging system – green plastic bubbles

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Bayhealth - Pak-Plus Bulk Packaging

Generic name

Strength

Brand name if available; otherwise

generic name

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Bayhealth - PakPlus Overwrap

packaging

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Knowing medication dose, route,

frequency and indication can help!

z Similar Indications

z Same patient population

z Identical Formulations

z Overlapping strengths or directions

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Summary

¾ Drug names, labels and packaging contribute

to medication errors

¾ Drug product characteristics as well as

processes at the facility can contribute to medication errors

¾ _{Organizations should systematically evaluate}

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Questions??

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References

z AHFS Drug Information Handbook 2007 z ASHP Pharmacist’s Drug Handbook 2007

z www.effexor.com

z www.fda.gov/cder/drugname

z Hoffman, J.M. & Proulx, S. Medication errors caused by confusion of drug names. Drug Safety 2003: 26(7),445-452 Retrieved September 22, 2004 from EBSCOhost. University of Phoenix online

z www.medpathways.info

z ISMP monthly bulletins

z http://www.clinpharm.medschl.cam.ac.uk/pages/teaching/documents/P rescribingPresentationNB.ppt#319,10,Spot the difference?

z http://www.prhi.org/pdfs/Look%20sound%20alike.pdf

z

http://web.ics.purdue.edu/~duffy/IE656_F2006/Lalaine-pt1-Reducng%20Medicatn%20Err.ppt#263,8,7 Categories of Medication Incidents : Preliminary Analysis

(www.rusty_lewis

www.effexor.com

www.fda.gov/cder/drugname

www.medpathways.info

http://www.prhi.org/pdfs/Look%20sound%20alike.pdf