Drug mix-ups occur frequently due to packaging and sound-alike drug
names
HARRISBURG, Pa., Sept. 27 /PRNewswire-USNewswire/ -- Medication errors
continue to rank high (23%) in the number of reports submitted to the
Pennsylvania Patient Safety Reporting System (PA-PSRS). The Patient Safety
Authority highlights the common causes of drug errors in its 2007 September
Patient Safety Advisory.
Unclear and confusing labeling and packaging as well as look-alike or
sound-alike drug names significantly contribute to medication errors,
according to data received by the Authority.
"Ambiguous and confusing packaging and labeling contribute to
medication errors," said John Clarke, MD, editor of the Patient Safety
Advisory. "Errors can occur because healthcare practitioners become
familiar with a certain package's appearance. When the package or label
looks similar to that of another product, or is changed, practitioners may
not realize the difference.
"Practitioners tend to see what is familiar rather than what is
actually there. If a drug has distinctive packaging, the potential for
mix-ups may be reduced," added Clarke. "Also, the more prominent parts of
the label are not necessarily the ones with the most important information
for those dispensing the medication."
Factors that relate to the medication's label or package that
contribute to the errors include: problems with readability of labels,
confusing expression of the drug's strength or concentration, over reliance
on color as an identifier and lack of contrast or visibility for important
label statements.
Michael Cohen, RPh, MS, ScD, president of the Institute for Safe
Medication Practices, a subcontractor with the Patient Safety Authority,
said drug packaging errors are nothing new.
"Although more and more pharmaceutical manufacturers take into account
how practitioners actually identify and use their products, that has not
always been the case," said Cohen. "Therefore, medication errors sometimes
occur when a product is misused."
The Advisory also highlights the increased potential for fatal drug
errors to occur between two sound-alike generic drug names: morphine and
hydromorphone. Hydromorphone is a common alternative to morphine for
treating pain if a patient cannot tolerate morphine; however, hydromorphone
is much more potent than morphine.
"One of the most common hospital-based sources of medication errors
involving confusion over potency is when a patient is improperly switched
from morphine to hydromorphone," said Cohen. "Further, analysis of wrong
drug errors submitted to PA-PSRS shows that mix-ups between these two
medications outnumber all other pairs of medications."
The potency difference in each is as follows: Oral hydromorphone is
approximately four times more potent than oral morphine; injectable
hydromorphone is approximately seven times more potent than injectable
morphine; and injectable hydromorphone is approximately 20 times more
potent than oral morphine.
"In seventy-one percent of the reports we received due to mix-ups
between morphine and hydromorphone, the errors occurred when these
medications were obtained from unit stock prior to administration," said
Cohen. "Facilities must be aware of how they are stocking these look-alike
and sound-alike drugs."
Cohen added that further analysis of the wrong drug reports involving
either morphine or hydromorphone shows that: 36% involve a mix-up between
these two drugs; 62% of the wrong drug reports involving both of these
drugs show morphine as the prescribed medication and hydromorphone given in
error; the most common care areas where this mix-up occurred were
medical/surgical units, medical/oncology units, emergency departments, and
telemetry units; and 34% of the reports involve elderly patients (patients
65 years and older).
The Patient Safety Advisory outlines strategies for facilities to avoid
mix-ups between morphine and hydromorphone, which account for the most
common and potentially serious errors that can occur involving two
high-alert medications (drugs that carry the risk of significant harm to
the patient if used incorrectly).
"The risk exists in almost every healthcare facility in Pennsylvania,"
said Cohen. "Facilities need to assume that this error will eventually
happen in their institution and consider taking the necessary steps while
storing and administering the medications to reduce the risk of error and
patient harm."
The strategies include: limiting hydromorphone access; reducing the
number of different strengths available for each drug; reducing look-alike
potential of the drug by using tall man lettering for emphasis on labels;
using technology such as bar coding and automated dispensing technology to
minimize the risk of error; requiring staff to double check the dose before
administering; monitoring patients closely before discharge; educating
staff with safety information about potent narcotics through newsletters
and in-service meetings; educating patients prior to administering
narcotics and repeating the name of the medication out loud to the patient
as another source of confirmation.
Cohen said further evidence that facilities need to rethink how they
store and administer look-alike and sound-alike drugs comes from the 13,000
reports of wrong drug medication errors collected by PA-PSRS.
"For the first time, we've listed the top twenty-five medication pairs
involved with wrong drug errors in Pennsylvania," said Cohen. "I hope
facilities take a look at the list and make the appropriate changes in
their facilities because many of them look and sound alike which increases
the risk for error."
Cohen added that the Joint Commission has established a National
Patient Safety Goal (goal 3C) to assure that hospitals address commonly
confused name pairs.
Of the 23% of all reports that are classified as medication errors, one
percent are considered serious events, or events that caused harm to the
patient. One in four (25%) medication errors involve a high-alert
medication.
Some other articles included in the 2007 September Advisory are as
follows:
-- Potential dangers in behavioral health facilities: PA-PSRS reports
indicate that patients continue to harm themselves in behavioral health
facilities by using structures and objects in the behavioral health
environment, particularly in patient rooms. Reviewing facility design,
staff and family education, and patient assessment, may help minimize the
risk. To view an interactive graphic of objects or structures in patients'
rooms that have contributed to patient harm, go to the Authority's website
at http://www.psa.state.pa.us.
-- Timeliness matters when transferring trauma patients: Pennsylvania
healthcare facilities have submitted reports to PA-PSRS describing problems
with transfers to trauma centers. The goal of a trauma system is to reduce
the burden of injury to patients by ensuring that they receive the best
care from the most qualified facilities as quickly as possible. Hospitals
also save time with efficient transfers, but reports show more can be done
to improve the delivery of patients from one facility to another.
-- Risks increased for patients with obstructive sleep apnea:
Obstructive sleep apnea (OSA) is a common sleep disorder that causes
recurrent episodes of complete and partial airway collapse during sleep,
resulting in the failure to breathe properly. Approximately 80-90% of OSA
patients are undiagnosed. Over 250 PA-PSRS reports show OSA as a
contributing factor for the event. About 20% of those are considered
serious events, including three deaths. The reports included medical and
surgical patients in both ambulatory surgical centers and hospitals. Learn
more about the risk factors, signs and symptoms, diagnosis and treatment
for OSA from the article. There is also a questionnaire on the Authority's
website that healthcare providers can distribute to patients prior to
surgery to help determine if they have OSA. Included is a "Consumer Tips"
sheet on what patients should look for to determine if they should see a
physician for OSA.
For a copy of the 2007 September Patient Safety Advisory, which
includes graphics of look-alike drug packaging and the top 25 drug pairs
involved in errors, go to
http://www.psa.state.pa.us/psa/lib/psa/advisories/sept_2007_advisory_v4_n3.
pdf. For more information on the Patient Safety Authority, go to
http://www.psa.state.pa.us.
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