I often speak with veterinarians who are concerned about doppelgänger drugs – medications with names that sound incredibly similar, or manufacturer’s bottles that look identical to one another. Veterinarians and pharmacists have to communicate and work together effectively to avoid misprescribing or filling the wrong prescription. There are serious consequences to filling the wrong prescription.
In a best case scenario, the patient’s ailment will not improve. Worst case scenario – the patient suffers complications that could prove fatal. Look-alike and sound alike drugs are a common cause of medication error and they pose an enormous risk to patient safety worldwide. There are steps that and pharmacy teams alike can implement to limit the danger of a mistake occurring.
1. Change Your Team’s Habits to Increase Patient Safety
Life is busy, and we all want more time, but one of the easiest ways to prevent a patient from receiving the wrong drug is for veterinary teams to take an extra moment to ensure their instructions are clear. Don’t call in a prescription while driving up your gravel driveway with the windows down or while you’re taking notes on another chart and eating your lunch.
Instead, try to make your prescription orders in a quiet place, so the pharmacy team member on the other end can hear you clearly. Be sure to slowly spell out the drug name and dosage, providing clear instructions, and repeating yourself as necessary. If you know that you have a speech impediment, accent, or register that makes you difficult to understand over the phone, take special care and have the pharmacy team member repeat the spelling and instructions back to you. If the prescription is written, make sure that your handwriting is clear or type out your orders to avoid mistakes.
Pharmacy team members can help by verbalizing their understanding when taking prescriptions over the phone or by calling the veterinarian if a written prescription is unclear in any way. Repeat back the spelling and the dosage, and have the veterinary team member confirm the prescription.
2. Ensure that Pharmacists Have Complete Knowledge of Drug Names and Usage
The drug industry is manufacturing new drugs at an rapidly increasing pace, so continued education and review will help prevent the most common medication errors. Teams need to annually review look alike-sound alike medications used by your veterinary team, and make sure that all team members understand the different uses of each medication.
Encourage the need to check the purpose of the medication as a “double-check” measure. For instance, if a veterinarian orders a known sound-alike medication, ask “Are you trying to treat dermatitis or cancer with this prescription?” Understanding the purpose of the medication will help limit an error on the veterinarian’s side as well.
Minimize the use of verbal and telephone orders to limit the possibility of error. For instance, you can use the phone to discuss medication options, but then fax over the official prescription.
3. Implement Protocol for Look Alike Medication Bottles
To avoid confusion caused by look-alike packaging, emphasize the importance of carefully reading the label each time a medication is accessed. Have the correct spelling of the medication handy. Train team members not to rely on less specific cues such as visual recognition or location, which can be altered at any time.
For well-known problem medications, consider storing them in a separate location.
Veterinary and pharmacy teams have to work together to limit the risks of misprescribing and filling the wrong medications. Institute protocols, and then make sure that everyone on the team is following them. Pharmacy team members should take extra care when filling prescriptions over the phone or when filling handwritten prescriptions. Veterinarians should take care to be as clear as possible, and encourage their pharmacy to follow processes that limit the possibility of medication error.
One of the easiest ways to limit medication errors is to type your prescriptions and send them electronically or via fax. Be sure to include indication on all of your prescriptions as a double-check for your pharmacy.