Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors (South Carolina)

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Summary:

Medication errors occur frequently in ambulatory prescribing, but little is known about the potential severity of look-alike, sound-alike (LASA) drug substitution errors and their frequency. LASA medication errors occur when a patient receives an incorrect medication because its name is spelled or sounds like another medication. While medication errors have been studied in the pediatric population, the frequency of LASA-specific errors in pediatric prescriptions is not documented or well understood.

This project evaluated the potential severity of specific LASA drug name substitution errors in a pediatric population and estimated the frequencies of potential LASA substitution errors.

The specific aims of this project were to:

  • Identify a subset of known LASA drug pairs that are prescribed in ambulatory pediatric care. 
  • Estimate frequencies of screening alerts (potential LASA substitution errors) in these drug pairs, and determine the positive predictive values (true positives) of the screening alerts.

A Delphi panel approach was used for the project. Thirty-seven practicing pediatricians evaluated LASA pairs identified in the literature, estimating the harm that might occur should a patient not receive the intended drug in any LASA pair, and the harm that might occur from erroneously receiving the delivered drug. After two rounds of surveys, the Delphi approach assessing harm of drug substitution identified 608 drug pairs of the original list of 1,784 un-duplicated pairs in the literature.

To estimate the frequency of the targeted list of LASA errors, South Carolina Medicaid paid claims data was used to identify patients 0-to-20 years of age who had received both drugs in a LASA pair within a 6-month period, representing a potential LASA substitution error. For 34 percent of the pairs, no patient received a substitution error. For 83 percent of pairs, the cumulative total of subjects who received both drugs amounted to less than one potential LASA error per day in the study population. By contrast, among the remaining 17 percent of pairs, there were 97,163 subjects who received both drugs, amounting to at least 27 potential LASA substitution errors per day.

This project advanced LASA error prevention in pediatric care by developing a prioritized list of LASA drug pairs commonly used in pediatric ambulatory care and considered at high risk to patients should a substitution occur. Such a targeted pediatric list did not previously exist. The data on the risk of harm of the LASA errors combined with the estimates of frequency of pediatric LASA drug substitutions, will allow the development of a prioritized list of high potential harm LASA substitution errors for future prevention efforts. In addition, the work laid the foundation for development of a larger-scale implementation study in pharmacy settings, with the goal of reducing LASA errors.

Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-268: Small Research Grant to Improve Health Care Quality Through Health Information Technology (IT) (R03)
  • Grant Number: 
    R03 HS 018841
  • Project Period: 
    April 2010 – March 2013
  • AHRQ Funding Amount: 
    $100,000
  • PDF Version: 
    (PDF, 214.33 KB)

Summary: Look-alike, sound-alike (LASA) medication errors occur when a patient receives an incorrect medication because its name is spelled or sounds like another medication. While medication errors have been studied in the pediatric population, the frequency of LASA-specific errors in pediatric prescriptions is not well documented or understood.

This study identified pediatric medications that are at the highest risk of causing harm through LASA errors and is refining a method for flagging individual prescriptions as potential errors and creating screening alerts. The research team used a modified Delphi approach with a panel of practicing general pediatricians to review a defined list of 200 LASA medication pairs. The error rates of these medication pairs were estimated by reviewing patient medication histories and diagnostic data. After estimation of the error rate, the positive predictive value will be identified for the screening alerts.

Research results could help guide the creation of a computerized set of pediatric-specific LASA screening alerts that could be implemented in pharmacies to reduce LASA errors for children. This research will lay the groundwork for development of a larger-scale implementation study in pharmacy settings, with the goal of reducing pediatric ambulatory LASA errors.

Specific Aims:

  • Identify a subset of known LASA drug pairs that are prescribed in ambulatory pediatric care. (Achieved)
  • Estimate frequencies of screening alerts (potential LASA substitution errors) in these drug pairs, and determine the positive predictive values (true positives) of the screening alerts. (Ongoing)

2012 Activities: The research team identified a subset of known LASA drug pairs that are prescribed in ambulatory pediatric care. After two rounds of provider surveys to build consensus on the degree of potential harm among the pairs, the team charted the responses in scatter plots and conducted cluster analysis to identify drug pairs for the final round of provider surveys. The cluster analysis produced a list of 608 drug pairs that was sent to providers for review in the third round of surveys. The Delphi process identified the drugs that the participants thought to be of high potential patient harm should a substitution occur. The 608 pairs included in the final round of the Delphi process were included in the final computations estimating the frequency of substitution errors.

Before running frequencies for the second aim, the team systematically identified duplicate entries in the Medicaid dataset to be used for the frequency analysis. The team used a Food and Drug Administration (FDA) file that cross-referenced the brand name and generic drugs that are the same drug but are listed under different names. The process took longer than expected because the FDA file was not complete and had to be supplemented by manual searches for additional brand names on Drugs.com and MedlinePlus.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and project budget spending is roughly on target. The project is somewhat behind schedule on the second aim, in part because of the time required to match generic and brand drug names. A 1-year no-cost extension is being used to complete the final analysis of frequencies of LASA drug pairs and document the results.

Preliminary Impact and Findings: The research team completed basic frequency calculations and have found that 207 of the 608 LASA drug pairs included in the final round of the Delphi process did not have a person who received both drugs in the pair within a 6-month period. This suggests that for these LASA pairs (34 percent of the total tested), it is highly unlikely that a patient received those substitution errors. It also suggests that screening for substitution errors for these pairs is feasible in the pharmacy setting, so any patient who receives both of these drugs within a 6-month period should be screened at the point of dispensing to make sure they are receiving the correct drug.

For 505 pairs (83 percent), the cumulative total of subjects who received both drugs in a pair was 3,610, amounting to less than one screening alert per day in South Carolina based on a review of 10 years of South Carolina outpatient Medicaid data.

On the other hand, the project team identified 20 LASA pairs (3 percent) where greater than 1,000 subjects received both drugs in the respective pair within a 6-month period. Their past research has suggested that up to 10 percent of these events represent likely LASA substitution errors. Even if the percentage of error in these new prescriptions is 10 percent, the fact that 3 percent of the LASA pairs were received by more than 1,000 subjects means that screening for potential substitution errors in these drug pairs will be very difficult as many patients appear to be receiving both drugs legitimately.

Target Population: Pediatric*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

* This target population is one of AHRQ’s priority populations.

Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-268: Small Research Grant to Improve Health Care Quality Through Health Information Technology (IT) (R03)
  • Grant Number: 
    R03 HS 018841
  • Project Period: 
    April 2010 - March 2012
  • AHRQ Funding Amount: 
    $100,000
  • PDF Version: 
    (PDF, 207.95 KB)

Summary: Look-alike, sound-alike (LASA) medication errors occur when a patient receives an incorrect medication because its name is spelled or sounds like another medication. While medication errors have been studied in the pediatric population, the frequency of LASA-specific errors in pediatric prescriptions is not documented or understood well.

This study is identifying pediatric medications that are at highest risk of causing child harm through LASA errors and refining a method for "flagging" individual prescriptions as potential errors and creating screening alerts. A modified Delphi approach with a panel of practicing general pediatricians is being used to define a target list of 200 LASA medication pairs. The error rates of these 200 medication pairs will then be estimated by reviewing patient medication histories and diagnostic data. After estimation of the error rate, the positive predictive value will be identified for the screening alerts.

Research results could help guide the creation of a computerized set of pediatric-specific LASA screening alerts that could be implemented in the pharmacy setting to reduce LASA errors for children. This research will lay the groundwork for development of a larger-scale implementation study in pharmacy settings, with the goal of reducing pediatric ambulatory LASA errors.

Specific Aims:

  • Identify a subset of known LASA drug pairs that are prescribed in ambulatory pediatric care. (Ongoing)
  • Estimate frequencies of screening alerts (potential LASA substitution errors) in these drug pairs, and determine the positive predictive values (true positives) of the screening alerts. (Ongoing)

2011 Activities: The project used a Delphi process to identify the LASA list of medications. An online survey facilitated the Delphi process, presenting 50 drug pairs to each of the 38 physician survey recipients. The survey questions were framed in the following form: "Let's say a child has to be on Adderall every day, and by mistake they get Inderal." The respondents are asked: "Please score the severity of the potential harm that might occur from not getting Adderall. Also, please score the severity of potential harm from getting Inderal by mistake." Dr. Basco and his research team have recruited pediatricians from around the country to participate and fill out the LASA survey. The third round of surveys were completed by physicians and in early 2012, the research team will complete the cluster analyses on third-round rankings in order to determine which pairs to include in the estimate of the frequency-of-substitution errors.

To measure the error rates of the final list of medication pairs, the research team will review patient medication histories and diagnostic data. The team has successfully obtained the Medicaid data for this component of the evaluation and has removed all duplicate entries. Further, they have identified a Food and Drug Administration file that contains cross-references for brand-name drugs with their corresponding generic names, allowing the electronic linkage of drugs that are the same but have different names.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track in some respects but not others. The project is somewhat behind schedule on the second aim to estimate frequencies of the potential LASA substitution errors, in part because of the time required to match generic and brand drug names. However, based on previously-done set-up work to develop a method for measuring frequencies of LASA substitution errors, the project team expects to meet milestones on schedule in 2012. Project spending is on target.

Preliminary Impact and Findings: Of the initial 1,784 LASA pairs, 917 were retained for the Delphi surveys. Participating physicians were able to identify pairs where the substitutions posed low potential harm (e.g. chlorpheniramine and cholestyramine), as well as pairs that represented high risk of harm for not receiving the intended drug (e.g. amiodarone and amantadine), high risk of harm for receiving the second drug in error (e.g. cetirizine and clonidine), and pairs where the potential harm was high from either not receiving the intended drug or from erroneously receiving the delivered drug (e.g. Tenex and Xanax).

The Delphi process was successful in identifying drugs that the participants felt were of high potential harm to a patient should a substitution occur.

Target Population: Pediatric*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-268: Small Research Grant to Improve Health Care Quality Through Health Information Technology (IT) (R03)
  • Grant Number: 
    R03 HS 018841
  • Project Period: 
    April 2010 – March 2012
  • AHRQ Funding Amount: 
    $100,000
  • PDF Version: 
    (PDF, 403.79 KB)


Target Population: Pediatric*

Summary: Look-alike, sound-alike (LASA) medication errors occur when a patient receives an incorrect medication because its name is spelled like or sounds like another medication. While medication errors have been studied in the pediatric population, the frequency of LASA-specific errors in pediatric prescriptions is not well documented or understood.

This study will identify pediatric medications that are at highest risk of causing child harm through LASA errors and refine a method for “flagging” individual prescriptions as potential errors. Research methodology will use a modified Delphi approach that uses a panel of practicing general pediatricians to define a target list of 200 LASA medication pairs. The error rates of these 200 medication pairs will then be estimated by reviewing patient medication histories and diagnostic data. After estimation of the error rate, the positive predictive value will be identified for the screening alerts.

Research results could help guide the creation of a computerized set of pediatric-specific LASA screening alerts that could be implemented in the pharmacy setting to reduce LASA errors for children. This research will lay the groundwork for development of a larger-scale implementation study in pharmacy settings, with the goal of reducing pediatric ambulatory LASA errors.

Specific Aims:
  • Identify a subset of known LASA drug pairs that are prescribed in ambulatory pediatric care. (Ongoing)
  • Estimate frequencies of screening alerts (potential LASA substitution errors) in these drug pairs, and determine the positive predictive values (true positives) of the screening alerts. (Ongoing)

2010 Activities: The project began by identifying the LASA list of medications. The team used two established lists, removed duplicates and, through the assistance of a clinical pharmacist, decided which drugs to remove from the entire list. Beginning with 17,000 medications, the team eliminated LASA pairs where one of the drugs in the pair is either IV, topical, or where the pairs represent similar drugs (e.g. extended-release versions of a drug versus the non-extended release version). This resulted in a list of 917 drug pairs that need further review. These are the drugs that will be included in the Delphi process to identify pairs that are of greatest concern to pediatricians should a substitution occur.

The Delphi process will occur through an online survey that was in development in 2010. After an initial pilot, the team made alterations to the form of the online survey and piloted the second version. Based on that feedback, the team altered the survey a third time to capture more detail on the reasons why the pediatricians made their decisions regarding any given drug pair.

The pairs will be presented reciprocally so there will be a total of approximately 1,800 pairs in the surveys. The grant team is now building 37 individual surveys to parse the 1,800 pairs into a manageable number for each survey participant. Each survey will have 50 drug pairs. The survey questions will be framed in the following form: “Let’s say a child has to be on adderall every day, and by mistake they get inderal.” The respondents score “How bad is it to get inderal by mistake? How bad is it to not get the adderall?” The principal investigator has recruited pediatricians from around the country to participate and fill out the LASA survey.

To measure the error rates of the final list of medication pairs, the team will review patient medication histories and diagnostic data. The team has successfully obtained the Medicaid data for this component of the evaluation and has removed all duplicate entries. Further, they have identified a Food and Drug Administration file that contains cross-references for brand name drugs with their corresponding generic names, allowing the electronic linkage of drugs that are the same but have different names.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): Progress is on track in some respects but not others. About 65 to 80 percent of the milestones are being met, but there is a viable plan for achieving the others, and the team is staying close to schedule. The process of developing the final list of drug pairs and developing the surveys has required more time than originally planned, however the project team expects to meet target date for data collection completion. Project spending is on track.

Preliminary Impact and Findings: The project has no findings to date.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

*AHRQ Priority Population.

Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors - Final Report

Citation:
Basco W. Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors - Final Report. (Prepared by the Medical University of South Carolina under Grant No. R03 HS018841). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 633.69 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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