where i used to work they had sound alike look alike drugs labeled with bright green or orange stickers. they put them in 2 different pixis to reduce risk of confusion.
In case the article vanishes, here's the disturbing beginning:
Quote:
Aspirin or heparin? Hydrocortone or Hydrocodone? Vioxx or Zyvox, or, maybe, Ziox? You'd think doctors, nurses and pharmacists would be able to keep these things straight--isn't that what they go to school for?--but in the chaos of a busy emergency room, or filtered through a noisy cell-phone connection, it's not surprising that communications sometimes go awry. For that matter, we ought to be able to keep these things straight ourselves, but patients waking up at 6 a.m. and stumbling into the bathroom to take a Zestril have been known to take a Zyrtec or a Zetia instead.
U.S. Pharmacopeia (USP), the nonprofit organization that sets national standards for purity and strength for drugs, tracked 26,000 incidents of patients receiving the wrong medication over a four-year period. (The study looked at a sample of about 10 percent of the nation's hospitals.) In 1.4 percent of those cases, a patient was harmed--occasionally, although rarely, fatally.
And the problem is growing, as hundreds of new drugs each year join the thousands already on the market but with no corresponding addition to the letters of the English alphabet. The last time USP examined the problem of look-alike and sound-alike drugs, in 2004, they found 1,750 pairs of potentially confusing names; this time there were 3,170, and they included, according to USP chief science officer Darrel Abernethy, each of the top 10 drugs sold in the United States.
How does it happen? USP's study found 71 different causes of error, including such nonobvious ones as "storage proximity errors"--people reaching for the bottle next to the one they wanted. Consider one case described by Dr. Julius Pham of Johns Hopkins involving a patient resuscitated after cardiac arrest. "A situation like that is chaotic, things need to occur rapidly, communication is all verbal," said Pham, who was in the ER that day. He ordered an IV of Levophed, a drug used to boost blood pressure rapidly, but the patient failed to respond. He ordered the dosage increased, then increased again, and as he looked over at the bag, he saw to his horror it actually contained Levaquin, an antibiotic. "For 10 minutes we were giving this patient an antibiotic," Pham said, adding: "this patient did not do well."
__________________ David
Co-Founder of DailyHealth.net
Insulin should be on the list too, you don't even want to the our pharmacy formulary list of "SALAD" drugs (Sound Alike, Look Alike Drugs) Heparin, Hespan (the drips are in the same style bag with simular lettering, and look at how close the names are too each other) Insulin drips are also in a simular bag, imagine heparin being given for DKA...all SALAD drugs are labeled on the MAR and if it's a Pyxis pull it makes us verify the drug before removing it from the pyxis (insulin is kept in the pyxis as an aside) And of course, Morphine, Hydromorphone and Meperidine...all pain medications. (You may reconize Dilaudid or Demerol better for the names of the second two drugs). I always ask for the spelling of a medication if I'm not sure what the doctor is ordering when I take a telephone order. BTW that annoys the doctors. With all the medications I'm giving for 5 patients tonight only 5 drugs come up as a SALAD alert, all are insulin (and only on two patients). Injectable Heparin pops as a SALAD because you could get the wrong strength (I don't even want to imagine that). I think it's good they are starting to notify the public that this is happening, maybe people will stop asking why it takes so long to get XYZ drug. It takes so long because with many drugs (insulin included) we have to find a second nurse to verify dosage with us. With narcotics we often have to have a nurse waste the amount with us because we don't use the entire vial.
Working in a Hospital and a Pharmacy, I remember the problems these "look alike names" were for me...Remember the tragedy of what happened to Dennis Quaids twins just a few months ago?
Unexceptable I say!!!
