Gupta, Bhavna

Gupta, Lalit

Kakkar, Kamna

Manohar, Manisha

English

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Ann Anesth Crit Care . 2018 October; 3(2):e79850.Published online 2019 April 10.doi: 10.5812/aacc.79850.LetterLook-Alike Drugs-‘A Wonder or a Blunder’?Lalit Gupta 1, Bhavna Gupta 2, *, Kamna Kakkar 3 and Manisha Manohar 11Department of Anaesthesia, Lok Nayak Hospital, Maulana Azad Medical College, New Delhi, India2Department of anaesthesia, All India Institute of Medical Science, Rishikesh, India3Department of Anaesthesia, Post Graduate Institute of Medical Sciences, Rohtak, India*Corresponding author: Assistant Professor, Department of Anaesthesia, All India Institute of Medical Science, Rishikesh, India. Tel: +91-8527686660, Email:bhavna.kakkar@gmail.comReceived 2018 May 27; Revised 2018 August 11; Accepted 2019 February 08.Keywords: Look-Alike Drugs, Administration, StandardDear Editor,Drug administration can be a precarious process in in-experienced hands. Inadequate operation theatre experi-ence or insufficient familiarity with the drug delivery de-vices, lack of plentiful supervision, or limited knowledgeabout drugs being administered can all lead to administra-tion of incorrect drugs to the patient. Even in experiencedhands, sometimes multiple factors dominate over com-mon sense and expertise- like fatigue, sheer carelessnessor poor communication with the team, haste in an emer-gency, poor labeling of drug, or distraction, which can leadto erroneous administration of drugs to the patient. Re-duced number of iatrogenic errors has always been an in-dicator of excellence in anesthesia practice, and a signifi-cant area of errors slithers in from prescribing medicationthat looks or sounds like an entirely different medication.There are standards of color coding in anesthesia forcylinders, gas pipelines, intravenous cannulas to ensurethe safety of the patients, but alas, similar measures havenot been developed to prevent wrong administration oflook-alike drugs. In fact, different manufacturers use theirown will in labeling drugs, which may be accidentallymisleading- for example morphine sulfate may be con-fused with morphine sulfate extended-release. Similarly,dexamethasone may be confused as dextromethorphan,oxycodone as oxycontin or tramadol as trazodone. In thesecircumstances, a standard naming and packaging of drugsbecome imperative, especially when different manufac-turers manufacture multiple different drugs in the samename, for example “Medzole” for midazolam, pantopra-zole and metronidazole, esomeprazole, itraconazole, al-bendazole, etc. (Figure 1). The errors are not just limited tooral or intravenous administration. Many errors have alsooccurred as drug administration in the intrathecal space,for example tranexamic acid ampoule looks strikingly sim-ilar to heavy bupivacaine, and has been administered acci-dentally in the intrathecal space (1), leading to catastrophicresults.According to 8th annual MEDMARX data report pub-lished by United States pharmacopeia, there were 1470 dif-ferent drugs, which are implicated in causing medicationerrors due to similar brand and generic names and com-piled a list of 3170 look alike and sound alike drugs (2).The fear of administration of the wrong drug is notonly limited to due to similar labeling however, due to thesimilar appearance of ampoules and vials too. This is verycommon practice in anesthesia to pick similar looking am-poules from the drug desk. When tired or during the weehours of an emergency duty, even the most conscientiousanesthetist can get unmindfully caught in such a situa-tion. The mishaps of this nature have been seen since, agesand it continues to be even reported in literature today (3).Confusion between drugs arises from similar labeling andpackaging, color and size of ampoules, names of drugs,strength and dosage forms, clinical use and frequency ofadministration and incomplete knowledge of drug names.The wrong drug administered as a result of human er-ror can lead to complete therapeutic failure, serious tox-icity, and unwarranted side effects and may even be fatalfor the patient. Simple vigilance is the minimum basicstep in avoiding any errors in the operation theater (OT)and the intensive care unit (ICU). Often, the drug errorsthat occur in the operating room cannot be reversed. How-ever, prevention is the best cure for such lethal effects thatcan occur because of drug administration. The followingstrategies can be considered for preventing such errors.Many disasters can be prevented if we have a standard-ized system of coding, for example color coding of differ-ent classes of drug ampoules according to an agreed na-tional or international standard. Contents of labels on am-Copyright © 2019, Annals of Anesthesiology and Critical Care. This is an open-access article distributed under the terms of the Creative CommonsAttribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just innoncommercial usages, provided the original work is properly cited.Gupta L et al.Figure 1. Multiple different drugs in the same name that manufactured by different manufacturerspoules and vials should be legible and must be standard-ized for font, size, and color. Appropriate instructions fromdrug regulatory authorities should be made and followedat all places. Labels should be periodically checked for anytear, removed label, or wrongly placed vial or ampoule (4).There should be a closed loop verbal communication in-volving the drug name and concentration made before ad-ministrating the drug between the drugs providers in OT(technician or resident) with the anesthetist in charge ofthe case. The drug should be drawn by the same residentwho labels the syringe. It is desired that drugs should bechecked independently and verbally verified before fillingthe syringe. Strict legible and bold labeled organizationof drug drawers should be considered with attention tothe position of ampoules and vials. Similar or dangerousdrugs should be segregated. Uncommonly used danger-ous drugs should be separated from the commonly useddrugs. Timely internal audits by a specific team (drugsafety officer and/or a pharmacist) to recheck organizationof drugs and names should be employed. Similar pack-aging and presentation of drugs should be avoided andbanned for further procurement by the hospital, wherepossible. Use upper case letters to emphasize differencesin medications with sound-alike names to aid in distin-guishing between the two. e.g., amLODIPine, amiTRIPTY-Line, morphine, HYDROmorphine, etc. (5). Avoid abbre-viations of drug names e.g. Atr for Atropine or, Atr forAtracurium (muscle relaxant), creating confusion. Onlypre-decided ampoules should be kept for the case and re-counting should be done at the end of each case to iden-tify any medication errors and to take measures to avoidfuture errors. Errors in intravenous drug administrationdue to look-alike drugs should be reported and reviewed.There should be time to time audits to minimize such er-rors. These errors can be reduced and eliminated by re-ducing physician working hours in OT due to the fact thatmany such errors are bound to happen by a resident whois fatigued or sleepy because of prolonged working hours.Training residents, especially the newer trainees, should besupervised by senior personnel in OT.Despite advancement in anesthesiology principles andmanagement, drug errors are known to occur in opera-tion theaters and ICU setting. Some of the drug errorsare minor, but some can cost a patient’s life. Errors creep-ing from look-alike drugs can be easily prevented by vig-ilance, surveillance, standardized coding, and protocolalong with a simple habit of reading the drug name twicebefore loading the drug in the syringe.FootnotesConflict of Interests: The authors declared no conflict ofinterests.Funding/Support: The authors declared no fund-ing/support.References1. Kaabachi O, Eddhif M, Rais K, Zaabar MA. Inadvertent intrathe-cal injection of tranexamic acid. Saudi J Anaesth. 2011;5(1):90–2.doi: 10.4103/1658-354X.76504. [PubMed: 21655027]. [PubMed Central:PMC3101765].2. U.S. Pharmacopeia . U.S. Pharmacopeia 8th annual MEDMARX(R) reportindicates look-alike/sound-alike drugs lead to thousands ofmedication er-rors nationwide. Rx Times; 2008.3. Wheeler SJ, Wheeler DW. Medication errors in anaesthesia andcritical care. Anaesthesia. 2005;60(3):257–73. doi: 10.1111/j.1365-2044.2004.04062.x. [PubMed: 15710011].4. Fasting S, Gisvold SE. Adverse drug errors in anesthesia, and the im-pact of coloured syringe labels. Can J Anaesth. 2000;47(11):1060–7. doi:10.1007/BF03027956. [PubMed: 11097534].5. FDA and ISMP lists of look-alike drug names with recommended tallman letters. [cited May 2018]. Available from: https://www.ismp.org/recommendations/tall-man-letters-list.2 Ann Anesth Crit Care . 2018; 3(2):e79850.

Look-Alike Drugs-‘AWonder or a Blunder’?

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Look-Alike Drugs-‘AWonder or a Blunder’?

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