A Survey on the Frequency of Medication Errors Caused Due to Look-Alike Drugs in the Emergency Department of the Educational Hospitals of Shiraz, Iran, 2016

Syedeh Zohreh Mosakazemi, Peivand Bastani, Milad Ahmadi Marzaleh, Mahmoud Reza Peyravi

Abstract


The words “look-alike” and “sound-alike” are used to express the confusion caused by drugs whose names or features are similar. Look-alike/sound-alike (LASA) drugs are one of the most common causes of medication errors. The emergency department is the first place where mistakes related to LASA drugs occur. Medicinal errors increase health care costs by about two billion dollars annually. This study examines the frequency of errors resulting from LASA drugs in the emergency department and identifies the main causes of these errors. This sectional analytical study was conducted in 2016 in the Namazi and Faghihi hospitals of Shiraz. The questionnaire was developed by the researcher and its validity was confirmed by the experts. The stratified sampling method was used and the sample size was determined to be 106 people, based on the Cochran formula. The data were analyzed using the software SPSS 20 by the Pearson correlation coefficient, the independent t-test, and an analysis of variance (ANOVA). Seventy-seven nurses stated that during the past six months they had made at least one error resulting from look-alike medication and a total of 132 errors were reported. The most common errors in medication related to ampoules and vials. The rate of errors was statistically significant in terms of marital status (p<0.05), work experience (p<0.0001) and age (p<0.0001). Providing training courses for recently appointed nurses, using experienced nurses in the emergency department can be an effective step toward reducing the errors relating to LASA drugs.

Keywords


Medication Errors, Nurses, Hospitals, Patient Safety, Workload, LASA drugs

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References


Ehsani SR, Cheraghi MA, Nejati A, Salari A, Esmaeilpoor AH, Nejad EM. Medication errors of nurses in the emergency department. Journal of medical ethics and history of medicine. 2013;6(11):1-7.

Jepson ZK, Darling CE, Kotkowski KA, Bird SB, Arce MW, Volturo GA, et al. Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process. BMC emergency medicine. 2014;14(1):20-12.

Buckle P, Clarkson P, Coleman R, Ward J, Anderson J. Patient safety, systems design and ergonomics. Applied ergonomics. 2006;37(4):491-00.

Donaldson MS, Corrigan JM, Kohn LT. To err is human: building a safer health system. United States: Washington,DC: National Academies Press; 2000. [5] Pham JC, Story JL, Hicks RW, Shore AD, Morlock LL, Cheung DS, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. The Journal of emergency medicine. 2011;40(5):485-92.

Aronson JK. Medication errors: definitions and classification. British journal of clinical pharmacology. 2009;67(6):599-04.

Schnoor J, Rogalski C, Frontini R, Engelmann N, Heyde C-E. Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system. Patient safety in surgery. 2015; 9(1):12.

Bryan R, Aronson JK, ten Hacken P, Williams A, Jordan S. Patient safety in medication nomenclature: orthographic and semantic properties of international nonproprietary names. PloS one. 2015;10(12): e0145431.

Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. International journal of clinical pharmacy. 2014;36(2):233-42.

Naunton M, Gardiner HR, Kyle G. Look-alike, sound-alike medication errors: a novel case concerning a slow-Na, slow-K prescribing error. International medical case reports journal. 2015;8:51-53.

Tuohy N, Paparella S. Look-alike and sound-alike drugs: errors just waiting to happen. Journal of emergency nursing. 2005;31(6):569-71.

Walliser G, Grossberg R, Reed MD. Look-alike medications: A formula for possible morbidity and mortality in the long-term care facility. Journal of the American Medical Directors Association. 2007;8(8):541-42.

Zhao R-y, He X-w, Shan Y-m, Zhu L-l, Zhou Q. A stewardship intervention program for safe medication management and use of antidiabetic drugs. Clinical interventions in aging. 2015;10:1201-12.

Chen M-J, Yu S, Chen I-J, Wang K-WK, Lan Y-H, Tang F-I. Evaluation of nurses' knowledge and understanding of obstacles encountered when administering resuscitation medications. Nurse education today. 2014;34(2):177-84.

Emmerton LM, Rizk MF. Look-alike and sound-alike medicines: risks and ‘solutions’. International journal of clinical pharmacy. 2012;34(1):4-8.

Kenagy JW, Stein GC. Naming, labeling, and packaging of pharmaceuticals. American Journal of Health-System Pharmacy. 2001;58(21):2033-41.

Basco WT, Ebeling M, Hulsey TC, Simpson K. Using pharmacy data to screen for look-alike, sound-alike substitution errors in pediatric prescriptions. Academic pediatrics. 2010;10(4):233-37.

Ostini R, Roughead EE, Kirkpatrick CM, Monteith GR, Tett SE. Quality Use of Medicines–medication safety issues in naming; look‐alike, sound‐alike medicine names. International Journal of Pharmacy Practice. 2012; 20(6): 349-57.

Schenkel S. Promoting patient safety and preventing medical error in emergency departments. Academic Emergency Medicine. 2000;7(11):1204-22.

Caterino JM, Emond JA, Camargo CA. Inappropriate medication administration to the acutely ill elderly: a nationwide emergency department study, 1992–2000. Journal of the American Geriatrics Society. 2004;52(11):1847-55.

Marcin JP, Dharmar M, Cho M, Seifert LL, Cook JL, Cole SL, et al. Medication errors among acutely ill and injured children treated in rural emergency departments. Annals of emergency medicine. 2007;50(4):361-67.

Rothschild JM, Churchill W, Erickson A, Munz K, Schuur JD, Salzberg CA, et al. Medication errors recovered by emergency department pharmacists. Annals of emergency medicine. 2010;55(6):513-21.

Fordyce J, Blank FS, Pekow P, Smithline HA, Ritter G, Gehlbach S, et al. Errors in a busy emergency department. Annals of emergency medicine. 2003;42(3):324-33.

Epstein SK, Huckins DS, Liu SW, Pallin DJ, Sullivan AF, Lipton RI, et al. Emergency department crowding and risk of preventable medical errors. Internal and emergency medicine. 2012;7(2):173-80.

Stratton KM, Blegen MA, Pepper G, Vaughn T. Reporting of medication errors by pediatric nurses. Journal of pediatric nursing. 2004;19(6):385-92.

Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. Jama. 1997;277 (4):307-11.

Peth HA. Medication errors in the emergency department: a systems approach to minimizing risk. Emergency medicine clinics of North America. 2003;21(1):141-58.

Bagheri-Nesami M, Esmaeili R, Tajari M. Intravenous Medication Administration Errors and their Causes in Cardiac Critical Care Units in Iran. Materia socio-medica. 2015;27(6):442-46.

Seidi M, Zardosht R. Survey of nurses' viewpoints on causes of medicinal errors and barriers to reporting in pediatric units in hospitals of mashhad university of medical sciences. Journal of Fasa university of medical sciences. 2012;2(3):142-47.

Mrayyan MT, Shishani K, AL‐FAOURI I. Rate, causes and reporting of medication errors in Jordan: nurses’ perspectives. Journal of nursing management. 2007;15(6):659-70.

Duarte SdCM, Stipp MAC, Silva MMd, Oliveira FTd. Adverse events and safety in nursing care. Revista brasileira de enfermagem. 2015;68(1):144-54.

Alqubaisi M, Tonna A, Strath A, Stewart D. Exploring behavioural determinants relating to health professional reporting of medication errors: a qualitative study using the Theoretical Domains Framework. European journal of clinical pharmacology. 2016;72(7):887-95.

Bahadori M, Ravangard R, Aghili A, Sadeghifar J, Gharsi Manshadi M, Smaeilnejad J. The factors affecting the refusal of reporting on medication errors from the nurses' viewpoints: a case study in a hospital in Iran. ISRN nursing. 2013;.

Lu M-C, Yu S, Chen I-J, Wang K-WK, Wu H-F, Tang F-I. Nurses' knowledge of high-alert medications: a randomized controlled trial. Nurse education today. 2013;33(1):24-30.

Esfahani AK, Varzaneh FR, Changiz T. The effect of clinical supervision model on high alert medication safety in intensive care units nurses. Iranian Journal of Nursing and Midwifery Research. 2016;21(5):482-86.

Farzi S, Farzi S, Alimohammadi N, Moladoost A. Medication errors by the intensive care units' nurses and the Preventive Strategies. Anesthesiology and Pain. 2016;6(2):33-45.

Taheri HabibAbadi E, Noorian M, Rassouli M, Kavousi A. Nurses’ perspectives on factors related to medication errors in neonatal and neonatal intensive care units. Iran Journal of Nursing. 2013;25(80):65-74.

Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R, Ardakani MT. Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: an observational study. Australian critical care. 2008;21(2):110-16.

Gorgich EAC, Barfroshan S, Ghoreishi G, Yaghoobi M. Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global journal of health science. 2016;8(8):220.

Salmasi S, Khan TM, Hong YH, Ming LC, Wong TW. Medication errors in the Southeast Asian countries: a systematic review. PLoS One. 2015;10(9):e0136545.

Kang J-H, Kim C-W, Lee S-Y .Nurse-Perceived Patient Adverse Events depend on Nursing Workload. Osong public health and research perspectives. 2016;7(1):56-62.

Yousefi M, Abed Saeedi Z, Maleki M, Sarbakhsh P. Frequency and causes of medication errors of nurses in different shift works in educational hospitals affiliated to Shahid Beheshti University of Medical Sciences. Journal of Shahid Beheshti School of Nursing & Midwifery. 2014;24(86):27-34.




Iranian Journal of Health, Safety and Environment e-ISSN: :2345-5535 Iran university of Medical sciences, Tehran, Iran