Medication Safety Overview

Medication Safety Overview Focus on Look-alike Sound-alike Medications Rita Montone, RPh, MBA Operations Manager Department of Pharmacy Bayhealth Medical Center

Medication names and packaging There are 15,000 brand medication names alone on the market Names for medications are a common cause As of June 2005, more than 399 problematic sets of confusing medication names Misunderstanding of medication names contributes to patient harm 2

How are medications named?? Each medication has three names Chemical name 4-chloro-N-furfuryl-5-sulfamoylanthranilic acid. Generic name furosemide Brand name Lasix (Hoescht) 3

Proprietary Name Concerns: May imbed dosing schedule Confusion when a suffix represents an indication for use Same suffix different interpretation 4

Brand Name Mis-recognition Examples Dimetapp Sudafed vs Sudafed PE Humibid LA Kaopectate 5

Proprietary Name Concerns: Fanciful Name Extenders 6 Zydis /

Effexor Confusion 7 Drug Generic Name(s) VENLAFAXINE HYDROCHLORIDE Brand Name EFFEXOR Strength(s) VENLAFAXINE HYDROCHLORIDE: 75 MG Imprint W 75 704 Drug Generic Name(s) VENLAFAXINE HYDROCHLORIDE Brand Name EFFEXOR XR Strength(s) VENLAFAXINE HYDROCHLORIDE: 75 MG Imprint W EFFEXOR XR75

Conceptual Reasons for Medication Errors Any or all of the following characteristics can contribute to the medication error: Generic name Brand name Dosage and/or strength supplied Dosage form Packaging 8

Conceptual Reasons for Medication Errors (cont.) Route, frequency Instructions for use Storage requirements Indications 9

Medication name confusion Generic or brand names sound similar May have similar indications Medication strengths may be available as identical formulations Storage may be in the same portion of the alphabet Suggestions TALLman lettering 10

11 AcuDose TALLman display

12 AcuDose Cabinet Display

13

Whirlwind of disruptions New / Changed Product Or Process Combo product Stress Dose Regimens Culture Marketing Brand names Care Process es Dose forms Computers Abbreviations Doses Legibility Team Nomenclature Patient Labels Care Communications Setting Routes Fatigue The Whirlwind Work of Symbols disruptionsindication condition Language Task Generic Human UBC names factors Storage Packaging Purchasing Preparation Knowledge Suffixes ERRORS! 14 www.fda.gov/cder/meeting The Whirlwind of disruptions

Medication Use System check points Prescribing Dispensing Administration Acquisition 15

Prescribing - Legibility of drug names Unasyn or Vancomycin? Protonix or Protamine? Capoten or Cozaar? 16

Dispensing - / - / - Purchasing 17 www.ismp.org

18 Dispensing - Purchasing

Look-alike / Carpuject packaging 19 www.ismp.org

Spot the difference? 20 Look alike IV bags contribute to medication errors

High Alert Medications at Bayhealth Medical Center Insulins (Humulin, Novolin, Humalog, NovoLog, Lantus) Heparin (low molecular weight) e.g. Enoxaparin, Heparin (unfractionated) Lidocaine IV Warfarin Potassium Chloride concentrate for injection 21

High Alert Medications at Bayhealth Medical Center (cont.) Propofol Moderate sedating agents for children (e.g. chloral hydrate) Total Parenteral Nutrition Dextrose (hypertonic -20% or greater) Cardioplegic solutions Sodium Chloride (hypertonic greater than 0.9%) Chemotherapeutic agents 22

Bayhealth Pharmacy-Nursing alert stickers 23 Healthcare Logistics

Saline Normal Saline is 0.9% (154mEq Sodium Chloride) per liter Hypertonic Saline is 3% (500mEq Sodium Chloride) per liter 23.4% sodium chloride (concentration 2.5mEq/ml) vial is needed for compounding TPNs as well as specialized saline solutions Stocked in Pharmacy Stocked in Dialysis 24

Look Alike Sound Alike Insulin Products Heparin ---- Hespan Warfarin ---- Avandia Morphine ---- Morphine (concentrated) (conventional liquids) Hydromorphone ---- Morphine Clonidine ---- Clonazepam 25

Insulin Issues, Packaging Factors Contributing to Errors 1. Similar Packaging 2. 10-mL vials same shape 3. Labels carry identical logos printed in the same style and color (in accordance with federal regulations) 26

Prescribing - Insulin Issues (labeling and nomenclature) Humulin Log ordered instead of Humulin-L (Lente). Nurse thought Humalog was to be given. 27

Insulin Issues (nomenclature) Similar names: Humulin vs. Humalog Lente vs. Lantus Novolog vs. Novolin Novolog vs. Humalog Novolin 70/30 vs. Novolog Mix 70/30 28

Handwriting example for: Heparin - Hespan HESPAN and Heparin share the characters "H-E," "P-A," and "N" in the same order HESPAN products may be packaged in premixed bags with coloring similar to heparin bags Often stored near one another due to their similar spelling. Heparin and HESPAN, when loaded into AcuDose, both names appear alphabetically similar as choices on the machine's computer screen. 29

Heparin Standardize concentrations for intravenous administration Use standardized protocols Requires ongoing monitoring; dosage adjustments Pre-mixed bag containing 25,000 units in 250ml D5W 100 units/ ml 30

Recommendations for Improvement Written communication Medication procedures Working environment Training and education 31

Handwriting example for: Coumadin ---Avandia 32 CAUTION! Poorly handwritten orders for AVANDIA (rosiglitazone), used to treat Type 2 diabetes mellitus, can look like COUMADIN (warfarin), used to prevent blood clot formation

Look Alike Sound Alike Morphine ---- Morphine (concentrated) Used to treat pain (conventional) Concentrated forms of oral morphine solution (20mg/ml) have often been confused with the The standard concentration of 10mg/5ml or 20mg/5ml Dispensing by volume instead of by mg dose 33

Look Alike Sound Alike Hydromorphone ---- Morphine Used to relieve pain Based on equi-analgesic dose conversion, this may represent significant overdosage Medication errors may result in episodes of respiratory arrest due to potency differences between these drugs 34

Narcotics and Opiates from Automated Dispensing Cabinets. Do not crush extended-release tablets Oral solutions are available in various levels Don t confuse morphine with hydromorphone Available as floorstock May be removed prior to pharmacist verification of patient medication order Allergic reactions are common 35

36

37 Dosage forms: OxyContin or Oxycodone immediate release

Look Alike Sound Alike Clonidine ---- Clonazepam Catapres (clonidine) used to treated hypertension Klonopin (clonazepam) used to treat seizures The generic name of clonidine can be confused as the brand KLONOPIN. 38

Look Alike-Sound Alike (cont.) Serzone ---- Seroquel Zantac ---- Xanax Taxol ---- Taxotere Cisplatin ---- Carboplatin Epinephrine ---- Ephedrine Celebrex -- Celexa -- Cerebyx 39

Case Study Serzone vs Seroquel Serzone (nefazodone) for schizophrenia Seroquel (quetiapione) for depression Propensity for errors include: Name Dosing interval (both are twice daily) Dosage form (both are tablets) Dosage strengths ( both as 100mg and 200mg) Dosage titration (both incremental and targeted range) Storage in pharmacy (close, if by brand name) 40

Look Alike Sound Alike Zantac ---- Xanax Zantac (ranitidine) is a histamine H-2 receptor antagonist and is used to treat duodenal ulcers and prevent their return Xanax (alprazolam) is used to treat anxiety, panic disorders, tremor and insomnia 41

Look Alike Sound Alike Taxol ---- Taxotere Both medications used to treat cancer Confusion between these two drugs can result in serious outcomes Confusion when ordered as brand names Brand / Generic names TaxOL (PACLItaxel) TaxOTERE (DOCEtaxel) 42

Look Alike Sound Alike Cisplatin ---- Carboplatin Both medications used to treat cancer Confusion between these two drugs can result in serious outcomes Confusion when ordered as brand names Brand / Generic names Platinol-AQ (CISplatin) Paraplatin (CARBOplatin) 43

Look Alike Sound Alike Epinephrine ---- Ephedrine Adrenalin (epinephrine) A bronchodilator Used in the emergency treatment of allergic reactions Restore cardiac rhythm in cardiac arrest Ephedrine A bronchodilator TALLman lettering in computer and cabinets: EPINEPHrine vs ephedrine 44

Look Alike Sound Alike Celebrex -- Celexa -- Cerebyx Celebrex (celecoxib) COX-2 antiinflammatory agent Celexa (citalopram) used to treat depression Cerebyx (fosphenytoin) used to treat seizures 45

Celexa - Celebrex Celexa 20mg Celexa 40mg Celebrex 100mg Celebrex 200mg 46

47 Look alike-sound alike alerts

Technology Update - Bar Coding Drugs NDC Number NDC can be contained in: Universal Product Code Number (UPC) International Article Number (EAN) Global Trade Item Number (GTIN) NDC Number - Administered by FDA - Center for Drug Evaluation and Research (CDER) Labeler Code: Manufacturer, repackager or distributor Unique number assigned by Labeler for strength, dosage form, and formulation for a particular firm Trade Package Size and Type Other information such as lot number and expiration date maybe optionally (www.rusty_lewis presentation) 48

Barcode Technology 49 Series of vertical lines and spaces that scanner converts to electrical signal understood by computer Used in grocery stores since 1970s Can store alpha and numeric and information Provides accurate, fast, real-time data collection and entry Offers exceptional security Minimizes errors associated with manual data entry

Packaging Universal look to unit-dose packaging if often misleading whether purchased in manufacture unit-dose packaging OR Packaged in the hospital pharmacy utilizing the medi-dose packaging system green plastic bubbles 50

Bayhealth - Pak-Plus Bulk Packaging Generic name Strength Brand name if available; otherwise generic name 51 NDC number; Bar-coding & Expiration date

52 Bayhealth - PakPlus Overwrap packaging

Knowing medication dose, route, frequency and indication can help! Similar Indications Same patient population Identical Formulations Overlapping strengths or directions Stored in the same areas 53

Summary Drug names, labels and packaging contribute to medication errors Drug product characteristics as well as processes at the facility can contribute to medication errors Organizations should systematically evaluate each high-risk medication 54

Questions?? Thank you 55

References AHFS Drug Information Handbook 2007 ASHP Pharmacist s Drug Handbook 2007 www.effexor.com www.fda.gov/cder/drugname Hoffman, J.M. & Proulx, S. Medication errors caused by confusion of drug names. Drug Safety 2003: 26(7),445-452 Retrieved September 22, 2004 from EBSCOhost. University of Phoenix online www.medpathways.info ISMP monthly bulletins http://www.clinpharm.medschl.cam.ac.uk/pages/teaching/documents/p rescribingpresentationnb.ppt#319,10,spot the difference? http://www.prhi.org/pdfs/look%20sound%20alike.pdf http://web.ics.purdue.edu/~duffy/ie656_f2006/lalaine-pt1- Reducng%20Medicatn%20Err.ppt#263,8,7 Categories of Medication Incidents : Preliminary Analysis 56