Evaluating the Potential Severity of Look-Alike, Sound-Alike Drug Substitution Errors in Children

Abstract

Objective: Look-alike, sound-alike (LASA) drug name substitution errors in children may pose potentially severe consequences. Our objective was to determine the degree of potential harm pediatricians ascribe to specific ambulatory LASA drug substitution errors.

Methods: We developed a unified list of LASA pairs from published sources, removing selected drugs on the basis of preparation type (eg, injectable drugs). Using a modified Delphi method over 3 rounds, 38 practicing pediatricians estimated degree of potential harm that might occur should a patient receive the delivered drug in error and the degree of potential harm that might occur from not receiving the intended drug.

Results: We identified 3550 published LASA drug pairs. A total of 1834 pairs were retained for the Delphi surveys, and 608 drug pairs were retained for round 3. Final scoring demonstrated that participants were able to identify pairs where the substitutions represented high risk of harm for receiving the delivered drug in error (eg, did not receive methylphenidate/received methadone), high risk of harm for not receiving the intended drug (eg, did not receive furosemide/received fosinopril), and pairs where the potential harm was high from not receiving the intended drug and from erroneously receiving the delivered drug (eg, did not receive albuterol/received labetalol).

Conclusions: Pediatricians have identified LASA drug substitutions that pose a high potential risk of harm to children. These results will allow future efforts to prioritize pediatric LASA errors that can be screened prospectively in outpatient pharmacies.

Keywords: children; medication error; patient safety; prescription error.

Figure 1

Screen capture of REDCap survey instrument.

Figure 2

Scatterplot of round 3 mean scores for 608 look-alike, sound-alike (LASA) drug substitution errors. Each point on the plot above represents the mean score for each LASA pair, measuring the opinion-generated estimate of harm for not receiving intended drug (x-axis) and the opinion-generated estimate of harm for receiving the delivered drug in error (y-axis). Circles represent LASA pair errors where no patient received both drugs within 6 months of each other, and triangles represent pairs where at least 1 patient received both drugs within 6 months of each other, based on 10 years of pharmacy claims data studied.