Blue Chip Surgical Partners Vice President of Operations Regina E. Dolsen, RN, BSN, MA, outlines eight steps ambulatory surgery centers can take to reduce the likelihood of errors with look-alike/sound-alike drugs.
1. Establish color-coding system. It is worthwhile for ASCs to put in the time and efforts to create a labeling system with a variety of color codes to help ensure visual identification of medications and reduce the likelihood of mix-ups, Ms. Dolsen says. "The use of a labeling system in all areas within the ASC, such as carts, cabinets, narcotic cabinets, etc., provides consistency for staff and clarity," she says.
2. Separate medications similar in appearance. ASCs should identify the medications that are packaged in a similar manner or are similar in coloring and appearance, she says. "I would recommend [ASCs] organize these medications in locations such that items of the same color or packaging are not next to each other," Ms. Dolsen says.
3. Don't default to alphabetical organization. While it might be the easiest way to organize medications, using an alphabetical system could potentially increase the chance of errors. "Often, use of alphabetic organization is not the best practice," says Ms. Dolsen. "Organization of medications on the shelves, drawers, etc., so that items with the same or similar names are not next to each other is helpful."
4. Use online resources. The Food and Drug Administration and Institute for Safe Medication Practices websites (www.fda.gov and www.ismp.org) are great sources for examples and listings of the medications commonly referred to as look-alike/sound-alike drugs, Ms. Dolsen says. "The listings help ASCs identify their confusing medications and their specific look-alike medications," she says. "The Joint Commission website (www.jointcommission.org) also has information related to this topic."
5. Use "tall man" letters. The use of tall man lettering is another recommendation from Ms. Dolsen for highlighting medications that are similar. "Several studies have shown that highlighting sections of drug names using tall man letters can help distinguish similar drug names, making them less prone to mix-ups," she says. "FDA, ISMP, The Joint Commission and other safety-conscious organizations have promoted the use of tall man letters as one means of reducing confusion between similar drug names."
6. Make center-specific list of drugs. ASC leadership should work proactively to educate its staff to the center's specific medications that may appear confusing or are on the ISMP list. "Post a list that you have tailored to your specific center-approved medications in your medication area," Ms. Dolsen says. "This list, not the list you obtain from FDA or ISMP, will be pertinent to your center and your staff. Make a concentrated effort to keep this list accurate and current."
7. Seek out and utilize additional educational resources. Ms. Dolsen says ASCs should proactively educate their staff and physicians by finding and using resources available outside the facility. "There are a variety of alerts and resource articles that you can post to help educate staff and physicians," she says. "These postings help keep the information in front of the staff and keep them current."
8. Include medication errors in your QI program. "Medication error reduction programs and monitoring medication errors, included as part of the ASC's quality improvement program, are opportunities for ongoing management of this patient safety issue," says Ms. Dolsen.
Learn more about Blue Chip Surgical Partners.
Read more from Blue Chip:
- 7 Steps to Maintaining OSHA Compliance
- 5 Steps to Profitable Spine in Surgery Centers