I'm talking about errors associated with look-alike, sound-alike (LASA) drug names today because LASA problems offer concrete examples of risk points that dog clinicians involved in the medication use system. (For purposes of this discussion, my quick-and-dirty working definition of a risk point is "any underlying factor that predisposes to error.")
In the last post, I referred to new research confirming something you probably already know: healthcare professionals struggle with reporting mistakes, and we struggle with the fact that we are fallible when we're involved in errors. When people believe that “bad people” or “good people having a bad day” are individually responsible for most medical errors, it’s easy to see why reporting error and reconciling feelings of personal responsibility become burdensome. But reporting and reconciling become easier when you look for solutions that improve the nature of the process, not the nature of the people. Face it, we’re all going to have a bad day once in awhile, and, unfortunately, not all people are good.
(I recently spent a year as the Safe Medication Management fellow at the Institute for Safe Medication Practices. But, as you can read in my last post, I was tripped up by look-alike packaging of hand sanitizer and hand soap a few weeks back, proving yet again that “knowledge” does not trump “process.”)
Human error is typically a by-product of the systems we practice in, and with LASA errors, it’s hard to miss the risk points. The category of LASA-related errors exists because, frankly, drug names are often similar to one another. It's easy to see how words and phrases like "oxycodone and oxycontin" and "Novolog Mix 70/30 and Novolin 70/30" could be mixed up. Similarities like these regularly give rise to confusion, and yes, error. We see look-alike, sound-alike word confusion in other settings all the time: if you haven't seen "your" erroneously substituted for "you're" recently, you're reading better things than I am! But when word mix-ups have the potential to give rise to medication errors, stronger processes that guard against selecting the wrong one need to be in place.
Next time, I'll share data and some easy-to-access resources for preventing LASA errors. Maybe you have an example of a look-alike or sound-alike error to share? (If you do, tell your story in the “comments,” omitting identifying information. On Florence dot com we neither offer medical advice nor violate HIPAA regulations.)
So, good people, stay safe and come back soon!
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4 comments:
As an American who speaks limited Chinese, LASA carries a different dimension. At a restaurant in China, arguing that 'fish rice' (yu' mi) is not the corn (yu mi) dish I ordered becomes a humourous exchange, and an obvious mistake. Guo bao rou (a spicy pork dish) being confused with a dish prepared with dog, is a bit trickier, and likely less humourous to most Americans.
These translation errors similarly occur with those that speak English as a second language, so be considerate and accurate. In life critical arenas, take the few extra moments to make sure everyone understands what was said, as it seems likely it will be an innocent 3rd party that suffers the consequences.
Being served dog meat by accident would approach the "medication error" threshold of most Americans! Thanks for sharing!
In healthcare people often report "push back" when asking busy clinicians to repeat-back and verify mission-critical data (like drug names and doses). Wonder if this happens in other industries.... would a pilot be able to refuse to say, "one-five" and choose to use the word "fifteen"?
You ask a good question when you ask if a pilot would refuse to say "one-five." My father is a pilot and I've taken lessons (many years ago). I don't think a pilot would even consider saying "fifteen." It's not how they are taught. From the very basics of ground school how to communicate properly and safely is taught.
So why is it that it isn't taught as the very basics in all healthcare curricula.
Several years ago when I was a retail pharmacist I had a doctor actually refuse to tell me what her prescription said when I called to clarify it because I couldn't read it. She was offended and flat out refused to tell me what it said. Told me I was stupid if I couldn't read it.
I think the importance of tighter communication is being infused into the professional training nurses, pharmacists, and docs get now.
Maybe some current students will weigh in?
I remember feeling special as a student because I was learning to "crack code." When I figured out that this was not going to possible on a routine basis, it firmed up my decision to become an L&D nurse (where patients usually had a straightforward plan of care and the "blanks" were easier to fill in). :-)
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