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"Prescription mapping" can improve efficiency while minimizing errors with look-alike products



From the October 6, 1999 issue

PROBLEM:Look-alike drug names and packaging.sound familiar? This problem is one of the root causes in over half the errors reported through the USP-ISMP Medication Errors Reporting Program (MERP). Within the past week, we've had several drug name mix-ups reported. Among these has been the mix-up between ZYRTEC and
ZYPREXA which appears as a Safety Brief in this week's issue. In another case, ethambutol 1,000 mg was prescribed for an HIV patient with tuberculosis. However, the patient received one dose of the antiarrhythmic ETHMOZINE (moricizine) 1,000 mg before the error was discovered. In each case, the wrong drug was selected for distribution from alphabetized drug storage areas in the pharmacy. While storing drugs alphabetically can assist staff in locating drugs, it also increases the likelihood of a medication error, primarily from confirmation bias (for a description of confirmation bias, see "The five rights" ISMP Medication Safety Alert! April 7, 1999). Thus, even when staff members attempt to read labels carefully, they can easily overlook disconfirming evidence between the product in their hand and the picture of the product and drug name in their mind

SAFE PRACTICE RECOMMENDATION:Many readers are familiar with strategies we have recommended to reduce the potential for mix-ups between look-alike drugs. A few include changing the manufacturer of one product to reduce similarity with another, building alerts into the computer system to warn about error potential, applying auxiliary warning labels to drug products, and using bold print to clearly distinguish letters which differ in look-alike drug names on drug product and storage bin labels. We also have suggested moving the product from one hand to the other then rereading the label to assure that important information has not been obscured, reading the drug name backwards, and spelling the drug name out loud while reading the label. Some may be hesitant to implement another idea. Sacrifice alphabetized drug storage and easy drug location in order to implement one of the most effective error prevention strategies: separating products with look-alike names. However, a recent article [Beaudet C. Mapping products efficiently in a dispensary. The Efficient Pharmacist. 1(4):1-2), published by The Efficient Pharmacy Institute, Quebec, Canada - 514 685 3842] suggests increased efficiency and reduced potential for error by storing products according to prescription volume. For example, frequently used products would be stored closer to the center of fill stations and less frequently used products would be stored furthest away. Efficiency can be improved by significantly reducing the amount of time and distance that staff must travel when dispensing drug orders. Equally important, the potential for an error can be reduced. Arranging drugs by frequency of use will often separate different doses of the same product. It will also separate look-alike products if one is used at a different frequency than another. The author states that newer pharmacy computer software includes full "prescription mapping" features to assist staff in easy location of products.

USP provides an up-to-date list of look-alike drug names on the Internet (Click here). At a minimum, seek out and use the list to identify look-alike drug pairs used in your facility and move the less frequently used product in the pair away from central pick stations and other drug storage areas. Also limit computer mnemonics to include only the most frequently used drug in each look-alike name pair listed in the resource. Design a completely different mnemonic or require practitioners to enter the entire drug name for the alternate drug. Look-alike name pairs should not appear on the same screen.

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