Amicar

To protect your patients and yourself, learn how to avoid potentially dangerous medication errors caused by name confusion.

Case 1

While taking a medication order over the phone, a nurse mishears the word "Amicar" (a hemostatic) and instead gives the patient "Amikin" (an aminoglycoside). Soon after, the patient develops permanent renal damage.

Case 2

A pharmacist misreads "Equanil" (an antianxiety agent) as "Elavil" (an antidepressant). The patient dies after receiving 1.2 grams of Elavil within 24 hours, a massive overdose causing tricyclic toxicity.

The list could go on. Medical literature abounds with cases of medication errors that resulted from poorly written prescriptions or misunderstood verbal orders. Unfortunately, as the number of drugs increases, so does the likelihood of confusion-particularly among drugs whose names look ox sound alike.

In response to this growing problem, some drug manufacturers have voluntarily changed product names to reduce mix-ups. For example, Losec was changed to Prilosec to, avoid confusion with Lasix.

But any hastily scrawled drug name is ripe for misinterpretation. A prescriber's illegible handwriting could confound both the pharmacist who dispenses the medication and the staff nurse who administers it.

You can reduce the risk of error by learning about the most common look-alike and sound-alike drugs and by using good judgment when interpreting medication orders. For guidelines, see the accompanying charts-and always observe these five cardinal rules:

1. When reading or taking orders, always double-check. If a prescriber's medication order is illegible or she speaks too quickly for you to understand her, ask her for clarification or spelling.

2. When you aren't sure, don't guess. Even if you know what the patient is being treated for, resist the urge to assume you can figure out which drug the prescribes intended. A wrong guess could be disastrous.

3. When you don't know the drug,find out about it. Before administering an unfamiliar drug, consult a reference book. If what you learn suggests that the drug is inappropriate for your patient, call the prescribes for clarification.

4. When the drug's form seems odd, take heed. In some cases, the drug form is an important clue to a potential mix-up. For example, if your patient's main problem is conjunctivitis, an order for "RMS" (a suppository) wouldn't make sense. By checking with the prescribes, you'd discover that "HMS" (an ophthalmic solution) is the correct form.

5. When the dosage doesn't add up, speak up. Dosage amount also can clue you in to a mistake. For example, suppose that you read an order for "metaxalone 2.5 mg." Because the drug comes only in doses of 400 mg, you should investigate further. By contacting the prescribes, you'd find out that "metolazone," which comes in 2.5-, 5-, and 10-mg doses, was the intended drug.

These five rules can help you avoid problems, but don't overlook another obvious measure: Tell the patient what drug you're giving him. Hopefully, his health care provider has told him what drugs he'll be getting, and he can alert you if you mention an unfamiliar one.

BY BENJAMIN TEPLITSKY, RPH Brooklyn, N.Y

Copyright Springhouse Corporation Sep 2001
Provided by ProQuest Information and Learning Company. All rights Reserved