Are You Using the Correct Medication or a Look-Alike?

Five years have passed since the member states of the World Health Organization (WHO) gathered at the 72nd World Health Assembly and decided that September 17 should be recognized as World Patient Safety Day, acknowledging it as a global health priority.

WHO data indicate the following findings related to medical safety:

• 1 in 10 patients is harmed while receiving healthcare, and 3 million die as a result.
• More than half of these incidents could be prevented.
• Indirect costs could amount to several billion US dollars annually.

Given the magnitude of preventable harm related to medication use, in 2017, the WHO launched the third Global Patient Safety Challenge: Medication Without Harm with the goal of reducing serious and preventable harm related to medication by 50%. In addition, considering the volume of medication packages prescribed in 2023 by physicians in Spain’s National Health System, it is necessary to understand the most common types of medication errors to provide an effective and efficient response.

According to Spain s Institute for Safe Medication Practices (ISMP), the 10 types of medication errors detected in 2020 with the most serious consequences were the following:

• Errors due to omission or delay in medication
• Administration of medication to the wrong patient
• Errors related to allergies or known adverse effects of medications
• Dosing errors in pediatric patients
• Errors due to similarities in the labeling or packaging of marketed medications
• Errors associated with the lack of use of smart infusion pumps
• Errors due to accidental administration of neuromuscular blocking agents
• Incorrect intravenous administration of oral liquid medications
• Errors in medication reconciliation upon hospital admission and discharge
• Errors due to patient misunderstandings regarding medication use

I would like to focus on the fifth item, errors due to similarities in the labeling or packaging of marketed medications.

Medications with similar names or with similar labeling or packaging are known as “look alike–sound alike” medications. They are estimated to account for between 6.2% and 14.7% of all medication errors. Confusion can arise due to spelling and phonetic similarities.

As shown in bulletin no. 50 of the ISMP, difficulties in distinguishing different medications or different presentations of the same medication due to similar packaging and labeling have frequently been associated with reported incidents.

Most cases involve either medications marketed by the same laboratory with a design based on brand image or different medications marketed by different laboratories in screen-printed ampoules used in the same settings.

In 2020, the ISMP published 11 new cases of labeling or packaging that may promote errors on its website. It reported 49 incidents to the Spanish Agency of Medicines and Medical Devices.

Shortages caused by the COVID-19 pandemic have further contributed to these incidents, as healthcare facilities sometimes had to change the medications they usually acquired and purchase whatever was available, without being able to select products that would not be confused with existing medications in the facility.

The ISMP recommends the following general practices for healthcare institutions, professionals, and patients to prevent these errors:

• Develop short lists of easily confused medication names and distribute them among all healthcare professionals
• Prioritize medication names by active ingredient instead of brand name
• For similar names, highlight the differences in capital letters, eg, DOBUTamine, DOPamine
• For similar active ingredients, use brand names
• Avoid placing similar medications near each other
• Prescribe all medications electronically to minimize the risk of selecting the wrong medication
• Make manual prescriptions legible, with clearly written dosages and pharmaceutical forms
• Encourage patients to actively participate in their treatment and consult a clinician if they have any questions about the medications they are receiving
• Raise awareness among patients, family members, and caregivers about the issues caused by medication name confusion and inform them about how to avoid these errors
• Instruct patients to focus on and always use the active ingredient name as an identifying element for the medications they are taking
• Review treatments with patients to ensure they know the medications they are taking

Julia María Ruiz Redondo is regional nursing advisor inspector of Spanish Society of General and Family Physicians of Castilla-La Mancha (SEMG-CLM), coordinator of the National Working Group on Public Health in the SEMG, and director of the international public health master’s degree at TECH Technological University. 

This article is the result of an editorial collaboration between the SEMG and Univadis, which you can access here. 

This story was translated from Univadis Spain, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.