Look-alike and sound-alike medicines: Risks and 'solutions'

International Journal of Clinical Pharmacy

Volumn 34, Issue 1, 2012, Pages 4-8

  Emmerton, Lynne M ^a,b   Rizk, Mariam F S ^b  

^a CURTIN UNIVERSITY   (Australia)

^b UNIVERSITY OF QUEENSLAND   (Australia)

Author keywords

Dispensing; Drugs; Errors; Human factors; Look alike sound alike; Medicines; Nomenclature; Packaging; Risks

Indexed keywords

AUSTRALIA; COMPUTER PROGRAM; DRUG PACKAGING; HOSPITAL PHARMACY; HUMAN; INTERVIEW; LINGUISTICS; MEDICAL ERROR; MEDICAL PRACTICE; NOMENCLATURE; PHARMACIST; PHARMACY; PRIORITY JOURNAL; REVIEW; RISK FACTOR; ARTICLE; COMPUTER ASSISTED DRUG THERAPY; INFORMATION PROCESSING; MEDICATION ERROR; METHODOLOGY; ORGANIZATION AND MANAGEMENT; PHARMACEUTICS;

AUSTRALIA; COMMUNITY PHARMACY SERVICES; DATA COLLECTION; DRUG PACKAGING; DRUG THERAPY, COMPUTER-ASSISTED; HUMANS; MEDICATION ERRORS; PHARMACY SERVICE, HOSPITAL; SOFTWARE; TECHNOLOGY, PHARMACEUTICAL; TERMINOLOGY AS TOPIC;

EID: 84860801072     PISSN: 22107703     EISSN: None     Source Type: Journal    
DOI: 10.1007/s11096-011-9595-x     Document Type: Review

References (20)

1. James KL, Barlow D, McArtney R, Hiom S, Roberts D, Whit-tlesea C. Incidence, type and causes of dispensing errors: a review of the literature. Int J Pharm Pract. 2009;17:7-8.
2. daCosta P. Medication errors: what to do about look-alike/sound-alike drug names. Drug Top. 2009;153:52.
3. Lambert BL, Lin SJ, Chang KY, Gandhi SK. Similarity as a risk factor in drug-name confusion errors: the look-alike (orthographic) and sound-alike (phonetic) model. Med Care. 1999;37:1214-25.
4. Joshi MC, Joshi HS, Tariq K, Ejaj A, Prayag S, Raju A. A prospective study of medication errors arising out of look-alike and sound-alike brand names confusion. Int J Risk Saf Med. 2007; 19:195-201.
5. daCosta P. Look-alike/sound-alike errors get more attention. Drug Top. 2009;153:52.
6. Hoffman JM, Proulx SM. Medication errors caused by confusion of drug names. Drug Saf. 2003;26:445-52.
7. MHRA. Report to the committee on safety of medicines from the working group on labelling and packaging of medicines. UK: medicines and healthcare products regulatory agency; 2001.
8. Tuohy N, Paparella S. Look-alike and sound-alike drugs: errors just waiting to happen. J Emerg Nurs. 2005;31:569-71.
9. The Joint Commission, USA. Sentinel event alert. Look-alike, sound-alike drug names: http://www.jointcommission.org/Sentinel Events/SentinelEventAlert/ sea-19.htm.
10. Beyea SC. Confusing, look-alike, and sound-alike medications. AORN J. 2007;86:861-3.
11. Gerrett D, Gale A, Darker I, Filik R, Purdy K. Tall man lettering. Final report of the use of tall man lettering to minimise selection errors of medicine names in computer prescribing and dispensing systems. ITQ invitation reference no. ER-07-0612. UK: National Health Service; 2009.
12. Sandhu G. Anticancer medication safety. J Pharm Pract Res. 2011;41(1):74.
13. Reason J. Human error: models and management. BMJ. 2000; 320:768-70.
14. Pettersson R. Attention: an information design perspective. Des Perspect. 2001;2:114-30.
15. Filik R, Purdy K, Gale A, Gerrett D. Labeling of medicines and patient safety: evaluating methods of reducing drug name confusion. Hum Factors. 2006;48:39-47.
16. Filik R, Purdy K, Gale A, Gerrett D. Drug name confusion: evaluating the effectiveness of capital (''tall man'') letters using eye movement data. Soc Sci Med. 2004;59:2597-601.
17. Van de Vreede M, McRae A, Wiseman M, Dooley MJ. Successful introduction of Tallman letters to reduce medication selection errors in a hospital network. J Pharm Pract Res. 2008; 38:263-6.
18. Gabriele S. The role of typography in differentiating look-alike/sound-alike drug names. Healthc Q. 2006;9:88-95.
19. Thompson CA. USP says thousands of drug names look or sound alike. Am J Health Syst Pharm. 2008;65:386-8.
20. Fleming H. Computer alert may help prevent sound-alike drug errors. Drug Top. 1999;143:1.