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1、Look-Alike and Sound-AlikeMedicationsPractitioner Perspectives,Timothy Lesar,Pharm.D.Director of PharmacyAlbany Medical CenterAlbany,NY,Practitioner perspectives,Evidence base for commentsDrug product medical care system interactions and risk for errorsSelect examplesImplications for risk reductionI
2、mplications for safety enhancements,Evidence base for comments,Systematic error detection,assessment,categorization and recording at AMC(since 1987)(32,000 prescribing errors)Nature of errors and contributors identified 20%related to drug names and nomenclatureLesar et al,JAMA 1990;263:2329-34Lesar,
3、Ann Intern Med 1992;117:537-8Lesar et al,Arch Intern Med 1997;157:1569-76Lesar et al,JAMA 1997;27:312-7Lesar,Arch Pediatr Adolesc Med 1998;152:340-4 Purdy et al,Ann Pharmacother 2000;833-8Lesar,J Gen Intern Med 2002;17:579-87Lesar,Ann Pharmacother 2002;36:1833-9,A GROWING PROBLEM:Number of dosage fo
4、rm related errors at AMC from 1996 to 2000(75%related to nomenclature),Emotional base for comments,Drug names,nomenclature and packaging:Often have a clear potential for error Commonly cause or contribute to patient harm.Cause or contribute to 2 or more significant medication errors every day at AMC
5、 Perception that safety is not always primary consideration in product naming.Simple product changes will reduce risk for error and enhance overall safety!,Conceptual Framework,Drug product inserted into complex care environment.Drug product interacts with care environment and care processes in iden
6、tifiable(often surprising)and predictable fashion.These interactions will be determined by specific product characteristics and specific care processes Errors occur in predictable ways!Allows risk assessmentAllows risk reductionAllows error prevention,Conceptual Framework,Risk for error and ADE Erro
7、r producing conditionsLikelihood of error occurringEnvironment and processes of careDrug(s)involvedPatient characteristic(s)Nature and type of error,Conceptual Framework,Any or all characteristics of a drug product can increase or decrease risk,and MUST be considered in risk assessment:Generic name,
8、brand nameDose,strength(s),dose form,packagingRoute,frequency,instructionsStorage requirementsIndications,patient populationLikely care environmentOther,Conceptual Framework,The medical care“vortex”,Drug product,ERROR,Stress,Care Processes,Brand names,Dose forms,Generic names,Doses,Routes,Communicat
9、ions,Labels,Symbols,Abbreviations,Legibility,Human factors,Storage,UBC,Packaging,Computers,Culture,Marketing,Workcondition,Fatigue,Language,Suffixes,Comboproduct,Patient,Indication,CareSetting,Preparation,Purchasing,New/Changed ProductOrProcess,Task,Team,Nomenclature,DoseRegimens,Knowledge,ERRORS!,S
10、elected Examples,Medication products in the medical care“vortex”,Predictable problems:Insulin brand names,Humulin“Log”ordered instead of Humulin-L(Lente).Nurse thought Humalog”was to be given.,Names and labels:Novolog is“regular”(“R”)insulin,right?,Dosage form names:OxyContin and MSContin,Dosage for
11、m names:Just a matter of time,0.5mg,1mg,2mg,3mg tablets,XR,Legibility and drug names,Capoten or Cozaar?,Protonix or Protamine?,Unasyn or Vancomycin?,Technology-drug product interface:Levophed for Lopressor,Why dose,route,frequency and indication are important:,Tricor for Tracleer,Error detected beca
12、use dose was different,Error NOT detected because dose was the same,Proscar in a female?,Practitioner perspectives Implications for risk reduction and safety enhancements,Predictable nature of errors allows risk assessment and reduction.Predictable nature of errors allows product design which can en
13、hance safety.All drug product characteristics must be considered in risk assessment and prevention.Care environment and processes must be considered in risk assessment and prevention.,Practitioners perspective Summary,Drug names,labels and packaging are major contributors to medication errorsRisk fo
14、r error is determined by both drug product characteristics and the care system processes.Risk assessment must include multiple drug characteristics(not just names)Risk of error within care system often readily apparent The predictable nature of errors provides opportunity for product naming and design which reduces risk and enhances safety.,
