Background: Confusion resulting from look-alike and sound-alike drug names and look-alike product packaging can result in potentially harmful medication errors. Case Study: A 69-year-old woman admitted to the oncology unit at a 670-bed teaching facility for correction of electrolyte imbalances was mistakenly administered Primacor® instead of potassium chloride, reflecting a look-alike packaging medication error. Actions Taken: The medical center developed and implemented process changes, including moving and reorganizing shelf storage bins, enhancing labeling for intravenous medications with similar packaging, tracking and responding to automated dispensing cabinet-filling errors, and revising processes for selecting and maintaining the list of look-alike, sound-alike medications to include the "real time" review of new medications added to the formulary and changes in packaging resulting from contract changes or drug shortages. Discussion: The Joint Commission National Patient Safety Goals for 2005 require organizations to identify and, at a minimum, annually review a list of look-alike, sound-alike drugs and to proactively implement safety strategies to help prevent medication errors involving these drug combinations. Proactive assessment of potential for medication errors should include evaluation of potential look-alike packaging problems in addition to the drug names.
Document Type: Research Article
Publication date: January 1, 2005
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Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.
Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety