TABLE 5

List of Error-Prone Abbreviations, Symbols and Dose Designations* Mistaken Abbreviations Q.D. mistaken for QID

AU, AS, AD mistaken for OU, OS, OD HS (half strength) mistaken for at bedtime ug mistaken for mg

SC or SQ mistaken for SL

HCT (hydrocortisone) mistaken for HCTZ

Mistaken Symbols @ or & mistaken as ‘ 2’

/ mistaken as ‘ 1’

+ mistaken as ‘ 4’ ° mistaken as ‘zero’

Mistaken Dose Designations ^{. 5 mg mistaken for 5 mg}

1.0 mg mistaken for 10 mg Conversion of mg to mcg

*Full list available at www.ismp.org/tools/errorproneabbreviations.pdf

scriptions. The study observed 280 near misses and 50 dispensing errors. A near miss is an error that did not produce patient injury or harm. The most common types of error in this phase were product selection, labeling and bagging errors. Errors also can occur during the transcribing phase, which includes documenting verbal orders, computer entry, order processing and reviewing the prescription. The monitoring phase involves identification and reporting of ADEs, re-evaluating the drug selection and regimen and assessing the patient’s response. This phase involves the prescriber, patient and pharmacist as they should all be involved with error reporting and monitoring of drug therapy.

of cellular phones and voice-mail messages. Errors caused by name confusion include brand-brand, generic-generic or brand-generic medication confusion. This is also referred to as “look-alike and sound-alike” drugs. Whether written or spoken, similarity of drug names accounts for 25 percent of the medication errors reported. ¹⁶ According to the 2005 ISMP’s List of Confused Drug Names, confusion is worsened by poor handwriting, incomplete knowledge of drug names, new products continually being approved, similar packaging and labeling or incorrect selection of a similar name drug from a computer list (Table 5). ¹⁷

ror can refer to the label on the immediate product container as designed by the manufacturer or the label on the dispensed product by the pharmacist. Errors in labeling as it relates to the manufacturer also can include an inaccurate or misleading package insert. The immediate container may look too similar to that of another manufacturer’s drug product, resulting in the wrong drug selection by the pharmacy. The label of the dispensed container to the patient, which occurs at the pharmacist’s level, may have wrong directions, wrong drug name, wrong strength or incomplete directions. Packaging and design by the manufacturer can lead to potential error if there is confusion due to the similarity of a drug’s color, shape and size to that of another product or the same product but in a different strength.

Causes of Error

Using the NCC MERP model for causes of error, communication is a key source of the problem. Specifically, the communication between a prescriber and pharmacist during a verbal or written prescription transaction. Miscommunication of written orders may be a result of illegible handwriting, dose miscalculations or misinterpretation of symbols abbreviations, units and decimal points. Misinterpretation from verbal orders also can occur especially with the use

In 2006, ISMP published an updated List of Error-Prone Abbreviations, Symbols and Dose Designations, which have been reported through the USP-ISMP Medication Error Reporting Program as being involved in medication errors. It is recommended that abbreviations, symbols or designations that appear on this list should not be used by prescribers (Table 6). ¹⁸

An updated List of High-Alert Medications, which are drugs that have a heightened risk of causing patient harm if used in error, was additionally published by ISMP in 2007 (Table 7). ¹⁹

Finally, human factors play an important role in analyzing why errors occur. As defined by AHRQ, human factors refer to the study of human abilities and characteristics as they affect the design and smooth operation of equipment, systems and jobs. ¹³ According to NCC MERP human factors include knowledge or performance deficit, transcription error, computer error and drug preparation error. Other causes for human error include fatigue, lack of sleep, illness, stress, workload, relationships with other employees and work environment (e.g., lighting, noise level and interruptions). ^{15, 20} According to IOM, although these factors can lead to error, the goal of patient safety and error prevention is to look beyond blaming individuals because this will do

little to make the system safer. Rather, steps should be taken to decrease the potential for human factors to result in an error. If fatigue is a factor, increasing the frequency of breaks or improving lighting may be steps that should be considered.

ROOT CAUSE ANALYSIS

Root cause analysis (RCA) is a structured process for identifying the casual or contributing factors that underlie the occurrence of adverse or critical incidents. ¹³ Root cause analysis is intended to determine what happened in a given situation, why it happened and what can be done to reduce the likelihood of a recurrence. ²¹ Root cause analysis directs attention away from an individual and toward a systems-based approach. This makes it possible to not only identify the factors that contributed to an error but, importantly, to take steps to minimize or eliminate those errors. For example, an analysis that concluded that a noisy environment contributed to misunderstanding information communicated over the phone would lead to steps to reduce the amount of noise in the environment or to instituting a procedure by which all information is repeated back for confirmation of accuracy. This is in contrast to the approach of blaming the individual(s) involved. In a process that seeks to focus on the individual, the suggested “solution” might be to tell the individual to pay more attention when receiving information over the phone.

error occurrence, errors are likely to continue to take place despite the individual at fault being reprimanded or dismissed from their job. Most people do try to do a good job. However, the mediation use process is complex and requires attention to many details. Improving systems and including checks and verification steps are necessary to decrease the potential for mistakes and errors.

Root cause analysis can help practitioners identify factors that influence error and provide that education to their staff. Preliminary data, including case reports and error rates, show this process can improve professionals’ willingness to report errors, as well as minimize and prevent future errors.

Failure Mode and Effects Analysis (FMEA) is another

TABLE 6

List of Confused Drug Names*

Drug name Confused drug name

Accupril Aciphex Adderall Inderal Avandia Coumadin Celebrex Celexa Zyrtec Zantac Serzone Seroquel

*Full list available at www.ismp.org/Tools/confused drugnames.pdf

TABLE 7

List of High-Alert Medications*

IV beta-blockers
Chemotherapeutic agents
Oral hypoglycemics
Insulin
Warfarin
*Full list available at www.ismp.org/Tools/high-
alertmedications.pdf

Although human factors do play a role in medication

tool used to reduce the frequency and consequences of error. ³ The difference between these two tools is that FMEA analyzes the system prior to implementation (prospective analysis) while RCA looks at the system already in place (retrospective analysis). ^{3, 22} FMEA considers how a sys-