Look-alike-sound-alike risks with flu vaccine and insulin may not be something you normally consider, but the risk of patient harm is extremely high. Do you have a facility specific look-alike-sound-alike list? Is it updated annually and posted in areas of medication administration? As a consultant pharmacist, I have the following five suggestions for minimizing risks and increasing patient safety.
High-alert and hazardous medications bear a heightened risk because they can cause significant patient harm and/or sentinel events when they are used in error. As a result, they require special safeguards. Look-alike/sound-alike (LASA) medications are those, either written or spoken, which may lead to potentially harmful errors when confused with each other. Keep in mind that it is possible for a medication to be on both the high-alert and LASA list. Insulin is only one example.
Influenza vaccine, on the other hand, may not be on either list, but the risk of confusion and patient harm is still great. Both insulin and influenza vaccine come in vials, are stored in the refrigerator, and are administered via injection. Over the last few years, there have been several documented cases of insulin being administered in error instead of the influenza vaccine, leading to hypoglycemia and hospitalization.
What can we do to minimize the risks?
- Identify high-alert and LASA medications in your facility: This is a perfect opportunity to work with your consultant pharmacist and rely on their expertise to develop a list based on your organization’s unique utilization patterns and internal data about medication errors. The Institute for Safe Medication Practices (ISMP) is also a good resource for starting this process. Remember, this is often a requirement of the certification and accrediting agencies such as the Centers for Medicare and Medicaid Services (CMS), Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (JC). In addition to increasing patient safety, you will also increase regulatory compliance.
- Segregate medications: Since these items are both stored in the refrigerator, physical separation is a little harder, but still doable. Segregate using different bins or locations within the fridge. Distinguish medications by using “tall man lettering”, (i.e. upper case letters). Finally, use stickers to identify the high-alert or hazardous medications on your organization’s list.
- Education: Ensure your list is continuously updated (at least annually) and your staff is aware of the contents and any changes. Keep the lists available in all areas where medications on your high-alert/hazardous and LASA medication lists are administered such as:
- medication rooms
- crash carts
- automated dispensers
- dental carts
- bulk storage medication cabinets
- narcotic lockers
- anesthesia carts
- block carts
- anesthesia work rooms
- treatment rooms
- immunization rooms
- Don’t guess!: If an order is unclear or you are unsure about the medication you are about to administer, ask. Although some environments can be intimidating, there is no harm in seeking clarification. It is much easier to ask and avoid causing patient harm than it is to correct the problem once the damage has been done.
- Clarify abbreviations: We are all familiar with The Joint Commission’s “DO Not Use” list, which of course are abbreviations we should avoid. This is a good starting point, but it doesn’t stop here. Clarify any abbreviations that are unclear and never use drug abbreviations in any communication. Abbreviations rarely save time and often lead to errors.
As a consultant pharmacist, I have many opportunities to make patients safer and work with my facilities to do so. Medication related events are one of the leading causes of patient harm and with a little effort, we can all contribute to a safer environment. Some risks are obvious, and others are not. If you are not working with a consultant pharmacist, consider adding one to your team because they can have a big impact on the patients in your care, and your regulatory compliance and liability. If you have questions or need some guidance on finding a consultant pharmacist, please reach out and we’d be happy to point you in the right direction.
The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.
