10-minute ISMP Survey on Look-Alike and Sound-Alike (LASA) Drug Names

Please take a few minutes to complete our short survey on look-alike and sound-alike (LASA) drug names, and submit your responses by April 17, 2009. We are very interested in the opinions of all staff involved in the medication use process, including unit secretaries who transcribe medication orders and pharmacy technicians who help dispense medications. Even if you know little about the topic, ISMP would sincerely appreciate your response to the survey. The survey is longer than usual only because the table for question 10 is detailed to make it easy for you to pick your responses. Completing the survey should only take about 10 minutes or less.

1. Does your organization maintain a targeted list of look-alike and sound-alike (LASA) drug name pairs that could be confused with each other?

Yes No Don’t know (If you answered “No” or “Don’t Know,” skip to question 13.)

2. Without looking at your organization’s LASA drug name pairs list, how many of the name pairs can you cite from memory?

None A few Half Most All

3. After checking your organization’s LASA drug name pairs list, how many drug name pairs are on it?

1-5 6-9 10 11-15 Greater than 15

4. How did your organization select the LASA drug name pairs on the list? (Check all that apply)

The Joint Commission LASA list
ISMP LASA list
USP LASA list
Professional or trade literature
FDA list of drug name pairs with recommended tall man letters
ISMP list of drug name pairs with recommended tall man letters
Staff reports of mix-ups or potential mix-ups between drugs with LASA names
Don’t know
Other:

5. Have you added any new drug name pairs to the LASA drug name pairs list since compiling the initial list in your organization?

Yes No Don’t know

6. Has your organization identified risk-reduction steps to reduce confusion between the drug name pairs on the list?

Yes No Don’t know (If you answered “No” or “Don’t Know,” skip to question 13.)

7. Has your organization implemented all or some of the risk-reduction steps identified for your organization?

Implemented all Implemented some Implemented none Don’t know

8. How did your organization establish the risk-reduction steps for the list of LASA drug name pairs? (Check all that apply)

Analysis of your medication use system
Best practices/recommendations in the literature
The Joint Commission website
ISMP website/resources
Staff suggestions
Safety-focused committee deliberations
Don’t know
Other:

9. Do the risk-reduction steps taken in your organization address the following phases of the medication use process?

Procurement:	Yes No Don’t know
Prescribing:	Yes No Don’t know
Dispensing:	Yes No Don’t know
Drug Storage:	Yes No Don’t know
Transcribing:	Yes No Don’t know
Administration:	Yes No Don’t know

10. Please tell us whether your organization has employed the risk-reduction steps listed in column A.

A. Risk-reduction Steps	B. Are the steps taken in your organization?
1.Limit Access
a. Avoid unit stock of certain concentrations, strengths, forms	Yes Fully Yes Partly No Don’t Know
b. Dispense the targeted drugs in unit doses	Yes Fully Yes Partly No Don’t Know
c. Limit use to a single product/strength	Yes Fully Yes Partly No Don’t Know
d. Limit variety of stock in patient units	Yes Fully Yes Partly No Don’t Know
2 Separate Storage
a. Separate LASA drugs in pharmacy	Yes Fully Yes Partly No Don’t Know
b. Separate LASA drugs in patient units	Yes Fully Yes Partly No Don’t Know
c. Separate storage of different strengths, forms, and releases (e.g., immediate/sustained)	Yes Fully Yes Partly No Don’t Know
3. Differentiate
a. Stock potentially confused drugs in different strengths (e.g., morphine/HYDROmorphone)	Yes Fully Yes Partly No Don’t Know
b. Change appearance of LASA names on computer screens (e.g., bold font/color/tall man letters)	Yes Fully Yes Partly No Don’t Know
c. Change appearance of LASA names on shelves/bins (e.g., bold font/color/tall man letters)	Yes Fully Yes Partly No Don’t Know
d. Change appearance of LASA names on pharmacy labels (e.g., bold font/color/tall man letters)	Yes Fully Yes Partly No Don’t Know
e. Use auxiliary labels	Yes Fully Yes Partly No Don’t Know
f. Affix “name alert” stickers to areas where look- or sound-alike products are stored	Yes Fully Yes Partly No Don’t Know
4. Add Redundancy
a. Prescribe by brand and generic names	Yes Fully Yes Partly No Don’t Know
b. Include brand and generic names on MARs	Yes Fully Yes Partly No Don’t Know
c. Employ double checks (manual)	Yes Fully Yes Partly No Don’t Know
d. Employ double checks (technology—bar coding, electronic prescribing)	Yes Fully Yes Partly No Don’t Know
e. Print current medications daily from the pharmacy computer system for physician review	Yes Fully Yes Partly No Don’t Know
5. Improve Access to Information
a. Specify the drugs’ indication when prescribing medications	Yes Fully Yes Partly No Don’t Know
b. Display entire drug names on screen when stems are used as a mnemonic (e.g., “Met”)	Yes Fully Yes Partly No Don’t Know
c. Specify the dosage form, drug strength, and complete directions on prescriptions	Yes Fully Yes Partly No Don’t Know
d. Consider the possibility of name confusion when adding a new product to the formulary	Yes Fully Yes Partly No Don’t Know
e. Utilize computerized alerts to remind providers about potential problems	Yes Fully Yes Partly No Don’t Know
6. Include the Patient
a. Advise patients taking LASA drugs about the risk of mix-ups and how to avoid them	Yes Fully Yes Partly No Don’t Know
b. Encourage patients to question medications that look different than expected	Yes Fully Yes Partly No Don’t Know
c. Investigate patient concerns about drug appearance	Yes Fully Yes Partly No Don’t Know
7. Ensure Staff Awareness
a. Periodically educate staff involved in handling LASA drugs about risks and risk-reduction strategies	Yes Fully Yes Partly No Don’t Know
b. Ensure knowledge of differences among LASA drug name pairs (e.g., lipid vs. conventional products, morphine vs. HYDROmorphone)	Yes Fully Yes Partly No Don’t Know
8. Others Please list:

11. Do you believe the risk-reduction strategies taken in your organization to guard against confusion with LASA drug name pairs have been effective?

Yes No Don’t know

12. Do you believe the risk-reduction strategies taken in your organization to guard against confusion have prevented you from making a mistake?

Yes No Don’t know

13. Please check the category that best describes you.

Staff Pharmacist
Staff RN
Nurse Educator
Clinical Pharmacist
Staff LPN/VPN
Quality/Risk
Pharmacy Director/Manager
Nurse Clinical Specialist
Physician
Pharmacy Technician
Nurse Manager
Unit Secretary
Other: