Re: Re: Requested DocAlert: U.S. Pharmacopeia MEDMARX(R) Report Shows Look-Alike/Sou

January 31, 2008

Just a quick note. The pharmacy I was working at in Pennsylvania, JHACO had come

in and one of there requirements were that we had to tag all are sound alike

med's. So we had stickers made and had to go through the entire pharmacy and

Accudose machines and sticker all the med's that even came close to sounding

alike.

In a message dated 01/30/08 23:54:34 Eastern Standard Time, rxjm2002@...

writes:

Thank you so very much !

We have been hearing about Sound and Look A Likes for along time now.

I would have to say I agree 100% with it being the # 1 cause of all

problems. With the recent heparin overdoses being so fresh on our

minds this article brings this poignant topic closer to the vest.

If anyone would like t share their message of any known or newly

discovered look -a-likes or sound alike's on this site please feel free.

Respectfully,

Jeanetta Mastron CPhT BS

Pharm Tech Educator

F/O

>

> Requested DocAlert® h3{font-size:1em; color:black;}

ul{margin-top:0px;} sup{vertical-align: top; font-size: .75em;}

sub{vertical-align: bottom; font-size: .75em;} Dear Clinician, Here

is the information you requested (sourced from USP).

>

> FOR IMMEDIATE RELEASE

> CONTACT: Kim301/816-8241; sek@...

> U.S. Pharmacopeia MEDMARX® Report Shows Look-Alike/Sound-Alike Drugs

Lead to Rampant Med Errors Each of the top 10 most prescribed drugs

in America commonly confused with at least one other drug

>

> Rockville, Md., Jan. 29, 2008 — The 8th annual national MEDMARX®

Data Report released today by the U.S. Pharmacopeia (USP) revealed

that more than 1,400 commonly used drugs are involved in errors linked

to drug names that look alike or sound alike. According to findings in

the MEDMARX report, 1.4% of the errors resulted in patient harm,

including seven errors that may have caused or contributed to patient

deaths. However, due to widespread underreporting of incidents, the

study's authors believe that the number of adverse events resulting

from look-alike/sound-alike errors is actually understated.

>

> For this year's report, USP reviewed more than 26,000 records

submitted to the MEDMARX database from 2003 to 2006. These records

revealed that 1,470 different drugs are implicated in medication

errors due to brand and/or generic names that looked or sounded alike.

From this data, USP compiled a list of 3,170 pairs of names that look

and/or sound alike. This result is nearly double the 1,750 pairs that

were identified in USP's previous report on this topic in 2004.

>

> In response to the findings, USP is calling on prescribers and

pharmacists to include an " indication for use " on prescriptions.

Indication for use is a phrase that signals why the patient is taking

the drug (e.g. cough, infection, rash). To prevent medication errors,

USP recommends that this powerful piece of information be conveyed at

several points along the health care continuum. Additionally,

prescribers should use trustworthy decision-support tools to help

ensure accuracy. Tools such as Epocrates Rx® free drug reference,

Lexi-Drugs, and others have been helpful in reducing potential

medication errors, and the addition of MEDMARX look-alike/sound-alike

data will make such tools even stronger.

>

> " Errors resulting from look-alike, sound-alike drugs are a problem

that spans the entire health care system, " said Darrell Abernethy,

M.D., Ph.D., chief science officer, USP. " By recording and

communicating not only the name of the drug, but also what it is being

used for, prescribers, pharmacists and consumers can work together to

dramatically reduce these types of medication errors. "

>

> Consumers picking up prescriptions should check the indication for

use appearing on the drug's label or ask their pharmacist for this

information. If the indication given by the pharmacy is different from

what the prescriber said the medication is for, that is a red flag for

the consumer to ask questions. Consumers should also exercise their

right to receive counseling from the pharmacist every time they begin

a new medication to ensure they know the name of the drug and its

pronunciation, what it is and how to take it.

>

> " This report brings a new dimension to USP's list of look-alike

and/or sound-alike drug names by providing additional evidence about

the many ways in which easily confused names can lead directly to

medication errors, " said Diane Cousins, R. Ph., USP's vice president

of healthcare quality and information and co-author of the MEDMARX

report. " The nation will now be able to access the most comprehensive

list of similar names that is based on actual reports of errors, and,

for the first time, a list that further delineates the error's effect

on patient outcomes. "

>

> The MEDMARX Data Report A Report on the Relationship of Drug Names

and Medication Errors in Response to the Institute of Medicine's Call

for Action analyzed records from 2003 to 2006 involving medication

errors due to drug names that look or sound similar. The report

includes the largest known list of look-alike, sound-alike drugs and

is the only list based on reported medication errors.

>

> USP's MEDMARX is an anonymous, Internet-accessible program used by

hospitals and related institutions nationwide to report, track, and

analyze medication errors. Since its inception in 1998, MEDMARX has

received more than 1.2 million reports of medication errors from more

than 870 health care facilities across the U.S. MEDMARX is the largest

nongovernmental, Internet-accessible database of medication errors in

the U.S. USP also operates, in conjunction with the Institute for Safe

Medication Practices, a Medication Errors Reporting Program (MER).

Data from MER, which allows health care professionals to report

potential and actual medication errors directly to USP on a

confidential and anonymous basis, were also used in compiling the

MEDMARX report. USP recently announced a strategic alliance with

Quantros™, providers of hospital applications. Under this arrangement,

the MEDMARX database will grow even larger and more robust with the

addition of Quantros' extensive

> patient-safety events database.

>

> # # #

> USP—Advancing Public Health Since 1820

> The United States Pharmacopeia (USP) is a private, non-profit,

standards-setting organization that advances public health by ensuring

the quality and consistency of medicines, promoting the safe and

proper use of medications, and verifying ingredients in dietary

supplements. These standards, which are recognized worldwide, are

developed by a unique process of public involvement through the

contributions of volunteers representing pharmacy, medicine, and other

health care professions, as well as science, academia, government, the

pharmaceutical industry, and consumer organizations. For more

information about USP and its four public health programs, visit

www.usp.org/newscenter. FY0822 The above message comes from " USP " ,

who is solely responsible for its content.

> You have received this email because you requested follow-up

information to an Epocrates DocAlert® Message. For more information

about DocAlert® Messages, please click here.

> Best wishes,

> The Epocrates Team

> 1100 Park Place, #300

> San Mateo, CA 94403

>

> ---------------------------------

> Never miss a thing. Make your homepage.

>

January 31, 2008

where I work we have a big issue of people putting

away drugs by how the packaging looks rather than

READING the label! I find things like clotrimazole

troches in the diphenhydramine bin. or acetaminophen

in the simethicone bin (these are unit doses from the

manufacturer)

--- CMTWHITE <cmtwhite@...> wrote:

Just a quick note. The pharmacy I was working at in

Pennsylvania, JHACO had come in and one of there

requirements were that we had to tag all are sound

alike med's. So we had stickers made and had to go

through the entire pharmacy and Accudose machines and

sticker all the med's that even came close to sounding

alike.

In a message dated 01/30/08 23:54:34 Eastern Standard

Time, rxjm2002@... writes:

> Thank you so very much !

>

> We have been hearing about Sound and Look A Likes

> for along time now.

> I would have to say I agree 100% with it being the #

> 1 cause of all

> problems. With the recent heparin overdoses being so

> fresh on our

> minds this article brings this poignant topic closer

> to the vest.

>

> If anyone would like t share their message of any

> known or newly

> discovered look -a-likes or sound alike's on this

> site please feel free.

>

> Respectfully,

>

> Jeanetta Mastron CPhT BS

> Pharm Tech Educator

> F/O

>

> >

> > Requested DocAlert® h3{font-size:1em;

> color:black;}

> ul{margin-top:0px;} sup{vertical-align: top;

> font-size: .75em;}

> sub{vertical-align: bottom; font-size: .75em;} Dear

> Clinician, Here

> is the information you requested (sourced from USP).

>

> >

> > FOR IMMEDIATE RELEASE

> > CONTACT: Kim301/816-8241; sek@...

> > U.S. Pharmacopeia MEDMARX® Report Shows

> Look-Alike/Sound-Alike Drugs

> Lead to Rampant Med Errors Each of the top 10 most

> prescribed drugs

> in America commonly confused with at least one other

> drug

> >

> > Rockville, Md., Jan. 29, 2008 — The 8th annual

> national MEDMARX®

> Data Report released today by the U.S. Pharmacopeia

> (USP) revealed

> that more than 1,400 commonly used drugs are

> involved in errors linked

> to drug names that look alike or sound alike.

> According to findings in

> the MEDMARX report, 1.4% of the errors resulted in

> patient harm,

> including seven errors that may have caused or

> contributed to patient

> deaths. However, due to widespread underreporting of

> incidents, the

> study's authors believe that the number of adverse

> events resulting

> from look-alike/sound-alike errors is actually

> understated.

> >

> > For this year's report, USP reviewed more than

> 26,000 records

> submitted to the MEDMARX database from 2003 to 2006.

> These records

> revealed that 1,470 different drugs are implicated

> in medication

> errors due to brand and/or generic names that looked

> or sounded alike.

> From this data, USP compiled a list of 3,170 pairs

> of names that look

> and/or sound alike. This result is nearly double the

> 1,750 pairs that

> were identified in USP's previous report on this

> topic in 2004.

> >

> > In response to the findings, USP is calling on

> prescribers and

> pharmacists to include an " indication for use " on

> prescriptions.

> Indication for use is a phrase that signals why the

> patient is taking

> the drug (e.g. cough, infection, rash). To prevent

> medication errors,

> USP recommends that this powerful piece of

> information be conveyed at

> several points along the health care continuum.

> Additionally,

> prescribers should use trustworthy decision-support

> tools to help

> ensure accuracy. Tools such as Epocrates Rx® free

> drug reference,

> Lexi-Drugs, and others have been helpful in reducing

> potential

> medication errors, and the addition of MEDMARX

> look-alike/sound-alike

> data will make such tools even stronger.

> >

> > " Errors resulting from look-alike, sound-alike

> drugs are a problem

> that spans the entire health care system, " said

> Darrell Abernethy,

> M.D., Ph.D., chief science officer, USP. " By

> recording and

> communicating not only the name of the drug, but

> also what it is being

> used for, prescribers, pharmacists and consumers can

> work together to

> dramatically reduce these types of medication

> errors. "

> >

> > Consumers picking up prescriptions should check

> the indication for

> use appearing on the drug's label or ask their

> pharmacist for this

> information. If the indication given by the pharmacy

> is different from

> what the prescriber said the medication is for, that

> is a red flag for

> the consumer to ask questions. Consumers should also

> exercise their

> right to receive counseling from the pharmacist

> every time they begin

> a new medication to ensure they know the name of the

> drug and its

> pronunciation, what it is and how to take it.

> >

> > " This report brings a new dimension to USP's list

> of look-alike

> and/or sound-alike drug names by providing

> additional evidence about

> the many ways in which easily confused names can

> lead directly to

> medication errors, " said Diane Cousins, R. Ph.,

> USP's vice president

> of healthcare quality and information and co-author

> of the MEDMARX

> report. " The nation will now be able to access the

> most comprehensive

> list of similar names that is based on actual

> reports of errors, and,

> for the first time, a list that further delineates

> the error's effect

> on patient outcomes. "

> >

> > The MEDMARX Data Report A Report on the

> Relationship of Drug Names

> and Medication Errors in Response to the Institute

> of Medicine's Call

> for Action analyzed records from 2003 to 2006

> involving medication

> errors due to drug names that look or sound similar.

> The report

> includes the largest known list of look-alike,

> sound-alike drugs and

> is the only list based on reported medication

> errors.

> >

> > USP's MEDMARX is an anonymous, Internet-accessible

> program used by

> hospitals and related institutions nationwide to

> report, track, and

> analyze medication errors. Since its inception in

> 1998, MEDMARX has

> received more than 1.2 million reports of medication

> errors from more

> than 870 health care facilities across the U.S.

> MEDMARX is the largest

> nongovernmental, Internet-accessible database of

> medication errors in

> the U.S. USP also operates, in conjunction with the

> Institute for Safe

> Medication Practices, a Medication Errors Reporting

> Program (MER).

> Data from MER, which allows health care

> professionals to report

> potential and actual medication errors directly to

> USP on a

> confidential and anonymous basis, were also used in

> compiling the

> MEDMARX report. USP recently announced a strategic

> alliance with

> Quantros™, providers of hospital applications. Under

> this arrangement,

> the MEDMARX database will grow even larger and more

> robust with the

> addition of Quantros' extensive

> > patient-safety events database.

> >

> > # # #

> > USP—Advancing Public Health Since 1820

> > The United States Pharmacopeia (USP) is a private,

> non-profit,

> standards-setting organization that advances public

> health by ensuring

> the quality and consistency of medicines, promoting

> the safe and

> proper use of medications, and verifying ingredients

> in dietary

> supplements. These standards, which are recognized

> worldwide, are

> developed by a unique process of public involvement

> through the

> contributions of volunteers representing pharmacy,

> medicine, and other

> health care professions, as well as science,

> academia, government, the

> pharmaceutical industry, and consumer organizations.

> For more

> information about USP and its four public health

> programs, visit

> www.usp.org/newscenter. FY0822 The above message

> comes from " USP " ,

> who is solely responsible for its content.

> > You have received this email because you requested

> follow-up

> information to an Epocrates DocAlert® Message. For

> more information

> about DocAlert® Messages, please click here.

> > Best wishes,

> > The Epocrates Team

> > 1100 Park Place, #300

> > San Mateo, CA 94403

> >

> > ---------------------------------

> > Never miss a thing. Make your homepage.

> >

> > [Non-text portions of this message have been

> removed]

> >

>

> [Non-text portions of this message have been

> removed]

>

" If the world were perfect, it wouldn't be. "

- Yogi Berra

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February 1, 2008

,

That's happening in retail. I've found Lovastatin 20mg in behind

Glyburide 5mg. They are both from the same manufacturer with the same

color scheme (green on white). It's frustrating, at the least.

Dangerous at the worst.

Della

On Thu, Jan 31, 2008 at 10:16 PM, karin h <hockeykatbird_27@...> wrote:

> where I work we have a big issue of people putting

> away drugs by how the packaging looks rather than

> READING the label! I find things like clotrimazole

> troches in the diphenhydramine bin. or acetaminophen

> in the simethicone bin (these are unit doses from the

> manufacturer)

>

February 1, 2008

YES I have heard of this around the country. Is this a FEDERAL LAW now ? or a

JCAHO recommendation? State law? which state?

Anyone know?

Jeanetta

CMTWHITE <cmtwhite@...> wrote: Just a quick

note. The pharmacy I was working at in Pennsylvania, JHACO had come in and one

of there requirements were that we had to tag all are sound alike med's. So we

had stickers made and had to go through the entire pharmacy and Accudose

machines and sticker all the med's that even came close to sounding alike.