Listen carefully: The risk of error in spoken medication orders

Social Science and Medicine

Volumn 70, Issue 10, 2010, Pages 1599-1608

  Lambert, Bruce L ^a   Dickey, Laura Walsh ^b   Fisher, William M ^c   Gibbons, Robert D ^a   Lin, Swu Jane ^a   Luce, Paul A ^d   McLennan, Conor T ^e   Senders, John W ^f   Yu, Clement T ^a  

^a UNIVERSITY OF ILLINOIS AT CHICAGO   (United States)

^b UNIVERSITY OF PITTSBURGH   (United States)

^c Independent Consultant ^*  (United States)

^d UNIVERSITY AT BUFFALO   (United States)

^e CLEVELAND STATE UNIVERSITY   (United States)

^f UNIVERSITY OF TORONTO   (Canada)

Author keywords

Auditory perception; Drug name confusion; Frequency; Medication error; Noise; Patient safety; Similarity; USA

Indexed keywords

MEDICINE; NEIGHBORHOOD; PERCEPTION; SIGNAL-TO-NOISE RATIO;

ACCURACY; ADULT; ARTICLE; CONTROLLED STUDY; FEMALE; HEARING ACUITY; HUMAN; HUMAN EXPERIMENT; MALE; MEDICATION ERROR; NURSE; PATIENT SAFETY; PHARMACIST; PHYSICIAN; PREDICTION; PRESCRIPTION; RISK ASSESSMENT; SIGNAL NOISE RATIO; STIMULUS RESPONSE; UNITED STATES; VERBAL COMMUNICATION;

ADULT; AGE FACTORS; AUDITORY PERCEPTION; FEMALE; HEARING; HUMANS; MALE; MEDICATION ERRORS; NURSES; PATIENTS; PHARMACISTS; PHYSICIANS; PRESCRIPTION DRUGS; RISK FACTORS; SEX FACTORS; SPEECH;

UNITED STATES;

EID: 77951653146     PISSN: 02779536     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.socscimed.2010.01.042     Document Type: Article

References (52)

1. Allinson T.T., Szeinbach S.L., Schneider P.J. Perceived accuracy of drug orders transmitted verbally by telephone. American Journal of Health-System Pharmacy 2005, 62:78-83.
2. Andrews S. The effect of orthographic similarity on lexical retrieval: resolving neighborhood conflicts. Psychonomic Bulletin and Review 1997, 4(4):439-461.
3. Aronson J.K. Medication errors resulting from the confusion of similar names. Expert Opinion on Drug Safety 2004, 3:167-172.
4. Balota D., Pilotti M., Cortese M. Subjective frequency estimates for 2938 monosyllabic words. Memory and Cognition 2001, 29(4):639-647.
5. Camp S.C., Hailemeskel B., Rogers T.L. Telephone prescription errors in two community pharmacies. American Journal of Health-System Pharmacy 2003, 60:613-614.
6. Carroll J.B. Measurement properties of subjective magnitude estimates of word frequency. Journal of Verbal Learning and Verbal Behavior 1971, 10:722-729.
7. Clopper C., Pisoni D., Tierney A. Effects of open-set and closed-set task demands on spoken word recognition. Journal of the American Academy of Audiology 2006, 17(5):331-349.
8. Cohen J.D., MacWhinney B., Flatt M., Provost J. PsyScope: a new graphic interactive environment for designing psychology experiments. Behavioral Research Methods, Instruments, and Computers 1993, 25(2):257-271.
9. Dr. orders liquibid-lithobid dispensed - death results. Case on point: Clifford v. Geritom Med., Inc., 681 N.W.2d 680-MN (2004). Nursing Law's Regan Report 2004, 45(2):4.
10. Flynn E.A., Barker K.N., Carnahan B.J. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. Journal of the American Pharmacists Association (Washington) 2003, 43(2):191-200.
11. Flynn E.A., Barker K.N., Gibson J.T., Pearson R.E., Smith L.A., Berger B.A. Relationships between ambient sounds and accuracy of pharmacists' prescription-filling performance. Human Factors 1996, 38:614-622.
12. Gernsbacher M.A. Resolving 20 years of inconsistent interactions between lexical familiarity and orthography, concreteness, and polysemy. Journal of Experimental Psychology: General 1984, 113:256-281.
13. Gonzalez J., McLennan C. Hemispheric differences in indexical specificity effects in spoken word recognition. Journal of Experimental Psychology: Human Perception and Performance 2007, 33:410-424.
14. Grossberg S. The adaptive self-organization of serial order in behavior: speech, language and motor control. Pattern recognition by humans and machines: Speech perception 1986, Vol. 1:187-294. Academic Press, New York. E.C. Schwab, H.C. Nusbaum (Eds.).
15. Hagmann P., Cammoun L., Martuzzi R., Maeder P., Clarke S., Thiran J.-P., et al. Hand preference and sex shape the architecture of language networks. Human Brain Mapping 2006, 27:828-835.
16. Hedeker D., Gibbons R.D. SuperMix mixed effects models from. http://www.ssicentral.com/supermix/index.html.
17. Hoffman J.M., Proulx S.M. Medication errors caused by confusion of drug names. Drug Safety 2003, 26(7):445-452.
18. Hosmer D.W., Lemeshow S. Applied logistic regression 1989, John Wiley & Sons, New York.
19. Howes D.H. On the relation between the intelligibility and frequency of occurrence of English words. Journal of the Acoustical Society of America 1957, 29:296-305.
20. IMS Health 2007 channel distribution by U.S. dispensed prescriptions Retrieved November 17, 2008, from. http://www.imshealth.com/deployedfiles/imshealth/Global/Content/Document/Top-Line%20Industry%20Data/2007%20Channel%20Distribution%20by%20RXs.pdf.
21. IMS I. National prescription audit plus 2001, IMS. Inc, Chicago, IL.
22. Jurafsky D., Martin J.H. Speech and language processing: An introduction to natural language processing, computational linguistics, and speech recognition 2000, Prentice Hall, Upper Saddle River, NJ.
23. Jusczyk P.W., Luce P.A. Speech perception. Stevens' handbook of experimental psychology: Sensation and perception 2002, Vol. 1:493-536. John Wiley and Sons, New York. 3rd. ed. H. Pashler, S. Yantis (Eds.).
24. Kleinbaum D.G. Logistic regression: A self-learning text 1994, Springer-Verlag, New York.
25. Koczmara C., Jelincic V., Perri D. Communication of medication orders by telephone-" writing it right" Dynamics 2006, 17(1):20-24.
26. Lambert B.L. Predicting look- and sound-alike medication errors. American Journal of Health-System Pharmacy 1997, 54:1161-1171.
27. Lambert B.L. Recent developments in the prevention and detection of drug name confusion. MEDMARX data report. A report on the relationship of drug names and medication errors in response to the Institute of Medicine's call for action 2008, 10-15. Center for the Advancement of Patient Safety, US Pharmacopeia, Rockville, MD. R.W. Hicks, S.C. Becker, D.D. Cousins (Eds.).
28. Lambert B.L., Chang K.-Y., Gupta P. Effects of frequency and similarity neighborhoods on pharmacists' visual perception of drug names. Social Science & Medicine 2003, 57:1939-1955.
29. Lambert B.L., Chang K.Y., Lin S.J. Descriptive analysis of the drug name lexicon. Drug Information Journal 2001, 35:163-172.
30. Lambert B.L., Chang K.Y., Lin S.J. Effect of orthographic and phonological similarity on false recognition of drug names. Social Science & Medicine 2001, 52:1843-1857.
31. Lambert B.L., Donderi D., Senders J. Similarity of drug names: objective and subjective measures. Psychology and Marketing 2002, 19(7-8):641-661.
32. Lambert B.L., Lin S.-J., Gandhi S.K., Chang K.-Y. Similarity as a risk factor in drug name confusion errors: the look-alike (orthographic) and sound-alike (phonological) model. Medical Care 1999, 37(12):1214-1225.
33. Lambert B.L., Lin S.-J., Tan H.K. Designing safe drug names. Drug Safety 2005, 28:495-512.
34. Lambert B.L., Lin S.-J., Toh S., Luce P.A., McLennan C.T., La Vigne R., et al. Frequency and neighbourhood effects on auditory perception of drug names in noise. Acoustical Society of America Journal 2005, 118(3):1955. Retrieved from. http://tigger.uic.edu/%7Elambertb.con_proceed/n05_173.pdf.
35. Lambert B.L., Yu C., Thirumalai M. A system for multi-attribute drug product comparison. Journal of Medical Systems 2004, 28(1):29-54.
36. Luce P.A., Goldinger S.D., Auer E.T., Vitevitch M.S. Phonetic priming, neighborhood activation, and PARSYN. Perception and Psychophysics 2000, 62:615-625.
37. Luce P.A., Pisoni D.B. Recognizing spoken words: the neighborhood activation model. Ear and Hearing 1998, 19(1):1-36.
38. National Center for Health Statistics Ambulatory health care data: NAMCS description Retrieved May 31, 2001, from. http://www.cdc.gov/nchs/about/major/ahcd/namcsdes.htm.
39. National Center for Health Statistics Ambulatory health care data: NHAMCS description Retrieved May 31, 2001, from. http://www.cdc.gov/nchs/about/major/ahcd/nhamcsds.htm.
40. Pennsylvania Patient Safety Authority Improving the safety of telephone or verbal orders. Patient Safety Advisory 2006, 3(2):1. Retrieved from, 3-7. http://www.psa.state.pa.us/psa/lib/psa/advisories/v3n2june2006/junevol_3_no_2_article_b_safety_of_telphone_orders.pdf.
41. Rodman J. The effect of bandwidth on speech intelligibility Retrieved June 17, 2005, from. http://www.polycom.com/common/pw_cmp_updateDocKeywords/0,1687,1809,00.pdf.
42. Selvin S. Statistical analysis of epidemiological data 1996, Oxford University Press, New York.
43. Solucient Inc Hospital drug utilization database Retrieved March 5, 2004, from. http://www.solucient.com/solutions/Solucients_Databases.shtml.
44. Sommers M.S., Kirk K.I., Pisoni D.B. Some considerations in evaluating spoken word recognition by normal-hearing, noise-masked normal hearing and cochlear implant users I: the effects of response format. Ear and Hearing 1997, 18:89-99.
45. Storker H.L. Methods for minimizing the confounding effects of word length in the analysis of phonotactic probability and neighborhood density. Journal of Speech, Language, and Hearing Research 2004, 47:1454-1468.
46. The Joint Commission Accreditation program: ambulatory health care, national patient safety goals Retrieved from. http://www.jointcommission.org/NR/rdonlyres/979098FA-74FD-4F25-AF41-EDD48FBD300E/0/AHC_NPSG.pdf.
47. U.S.Food and Drug Administration PDUFA pilot project proprietary name review. Federal Register 2008, 74(189):50806-50809.
48. Vitevitch M.S., Luce P.A. Probabilistic phonotactics and neighborhood activation in spoken word recognition. Journal of Memory and Language 1999, 40:374-408.
49. Vivian J.V. Third-party actions. US Pharmacist 2004, 11:74-78.
50. Wakefield D.S., Ward M.M., Groath D., Schwichtenberg T., Magdits L., Brokel J., et al. Complexity of medication-related verbal orders. American Journal of Medical Quality 2008, 23(1):7-17.
51. Wiener S.W., Liu S., Nelson L.S., Hoffman R.S. Nutropin or Neupogen? A medication error resulting in leukocytosis. Annals of Pharmacotherapy 2004, 38(4). 721-721.
52. Woolf S. The meaning of translational research and why it matters. Journal of the American Medical Association 2008, 299(2):211.