Call to Action: Standardization and Smarter Logic Needed to Prevent Drug Name Selection Errors
Problem: Since 2019, ISMP has recommended entering, at a minimum, the first five letter characters of a drug name (unless the name has fewer than five letters) during searches in automated dispensing cabinets (ADCs) when a needed item has not yet been added to the patient’s medication profile (during overrides) (see Statement 4.4 in the ISMP Guidelines for the Safe Use of Automated Dispensing Cabinets [www.ismp.org/node/1372]). Use of only the first two to four characters of the drug name (e.g., “met”), abbreviations (e.g., “mtx”), or a combination of the first few characters and dose (e.g., “meth10”) has led to the presentation of similar-looking drug names on the screen and has resulted in selection errors.
Despite its potential as a valuable safeguard, the five-character minimum approach is not without limitations and challenges when removing medications from an ADC via override, which we acknowledged in our 2021 article, Challenges with requiring five characters during ADC drug searches via override. These challenges include misspelling a drug name, needing spaces or symbols to meet the five-character minimum, difficulty locating combination medications or fluids, and failing to find emergency drugs (e.g., reversal agents) when forgetting about this requirement. Of course, to limit override challenges, whenever possible, orders should be entered and verified by a pharmacist to allow medication or product removal within the patient’s profile, thus, negating the need to enter five characters for product selection. Additionally, including the therapeutic class to the drug name listing or “pinning” emergency drugs to the top of the ADC screen could help prevent drug selection errors.
Vendors such as Omnicell and BD Pyxis have played a significant role in addressing the issue of wrong drug selections by demonstrating support for the five-character look-up minimum within their ADC functionalities. Omnicell unveiled a new safety feature in 2019, enabling cabinets to be configured to require a search of one to five characters for medications removed via override. BD Pyxis followed in 2022, offering a configurable search of three to five characters. To note, these functionalities require manual configuration and may necessitate a software update.
While these changes were a step in the right direction, we believe further technological advancements are necessary. A study,1 published in February 2024, examined safety strategies when searching for medications by name within health technology platforms. Researchers found that when looking at the number of overlapping characters in brand and generic medication names from left to right, medication name overlap varies widely. Some medication names overlap by only a few initial characters (e.g., INDERAL and INDOCIN); others overlap by seven or more initial characters (e.g., hydroxychloroquine and hydrOXYzine). Less frequently, medication names overlap by ten or more initial characters (e.g., PHENobarbital and PHENobarbital with belladonna alkaloids). For many lists of real-world medication names, worst case left-to-right character overlap varied from 4 to 29 characters, with the most frequent worst case being 14 overlapping characters. Looking just at high-alert medications, worst case overlap varied in these same lists from 3 to 10 characters, with the most frequent overlap being 6 characters. Instead of software requiring users to enter a fixed number of keystrokes, these findings provide insight into the value of keystroke disambiguation, a type of incremental search mechanism that uses each new keystroke to uniquely identify a single name of interest. We support the study’s conclusion that drug search safety can be improved by upgrading systems to respond dynamically to each keystroke entered.
The study described an additional safety concern: medication names may vary by organization and/or computer system (e.g., ADC, electronic health record [EHR], order entry system). Medication names listed in computer systems may not be standardized, could frequently be modified, and may be constrained by field length limits which may contribute to selection errors. Examples of non-standard real-world medication names provided by the researchers, in their article’s Supplementary Appendix A, includes various nicknames, brand names, and other names such as “1-2-3 cream,” “ara-c,” “dakin’s half strength,” “folic acid-vit b6-vit b12,” “mvw complete formulation,” and “tylenol #3.” Rather than individual organizations maintaining unique medication naming schemes for these and other drug products, the researchers recommend a standard list of medication names for computer systems.
Safe Practice Recommendations: While the five-character minimum remains a valuable interim strategy and ISMP continues to support its use, a more comprehensive approach, including dynamic search function capability, is needed to mitigate risks of ADC drug selection errors. To update medication name search mechanisms and strategies to prevent medication selection mistakes, consider the following recommendations:
For Vendors
Support a dynamic search function. Due to substantial variability in medication name overlap, the way medication names are represented and handled in software systems should be improved. Vendors should develop and implement an algorithm that allows users to enter the exact number of characters to get only one unique drug name to appear on the screen when searching for medication names on override.
Support standard medication names. Vendors should promote the use of standard medication names and presentations in all medication-use systems (e.g., “Tylenol with Codeine #3” as opposed to “Tylenol #3”). Vendors should remove length limits on medication name fields because these limits sometimes force those who configure medication-use systems to devise cryptic names.
For Organizations
Require indications for certain override medications. Previous studies have shown that indications are the most impactful product characteristic to differentiate between similar medication names.2,3 For high-alert and other potentially problematic medications, require users to confirm medication selection onscreen by selecting an indication or other verifying information. To streamline the indication selection process, build options derived from why the medication is on the override list (e.g., reversal agent). This is supported by Statement 8.4 in the ISMP Guidelines for the Safe Use of Automated Dispensing Cabinets (www.ismp.org/node/1372) which recommends configuring interactive alerts that require users to enter or select clinically relevant information prior to the removal of organization-identified medications. In addition, ISMP Targeted Medication Safety Best Practices for Hospitals, Best Practice 7 (www.ismp.org/node/160), recommends confirmation of clinically relevant information (e.g., the purpose for removing the drug, such as whether the patient is ventilated when removing a neuromuscular blocking agent).
Analyze workflow. Analyze the workflow, especially the searchability of emergency medications, and conduct a failure mode and effects analysis (FMEA) to identify and manage potential challenges before implementing the five-character search requirement or other dynamic search (if available) for medications obtained from an ADC via override. For examples of risk points to consider during the FMEA, review our 2021 article, Challenges with requiring five characters during ADC drug searches via override.
Use simulation to educate staff. Conduct simulations with users before implementing any drug name search changes. This allows users to gain familiarity and confidence with the new functionality, particularly in time-sensitive situations such as medical emergencies. Include simulation during orientation and annual competency assessments for relevant employees.
Establish a feedback mechanism. Develop a robust and effective communication plan and obtain feedback from frontline staff before implementing any changes in drug name searches. After implementation, collect data to assess any unintended consequences that are identified. To collect this data, include a dedicated log near the ADC or an online platform for users to document any challenges encountered. Evaluate reported issues and make appropriate adjustments as needed.
Standardize medication names used in medication systems. After medication names are determined through existing regulatory processes, a gold standard set of medication names could be developed to use in all medication systems. This list of names could come about through a national consensus standards-setting process. We recognize that there will still be an organizational decision to name a medication differently based on a safety concern. However, in an ideal state, the computer system software should automatically check that the organization’s medication name list conforms to the standard set of names or notify them of those that do not.
Stay informed about vendor updates. As we advocate for improved search functionalities by ADC vendors, it is important to activate software updates or upgrade technology when available. This approach ensures early access to the latest safety improvements offered by vendors.
References
- Flynn A, Mieure KD, Myers C. Using name overlap analysis to understand medication name search safety. Am J Health Syst Pharm. Published online February 24, 2024. doi:10.1093/ajhp/zxae048
- Cheng CM, Salazar A, Amato MG, Lambert BL, Volk LA, Schiff GD. Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs. J Am Med Inform Assoc. 2018;25(7):872–84.
- Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, Schiff G. Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. Expert Opin Drug Saf. 2017;16(10):1103-9.
Suggested citation:
Institute for Safe Medication Practices (ISMP). Call to action: standardization and smarter logic needed to prevent drug name selection errors. ISMP Medication Safety Alert! Acute Care. 2024;29(11):1-3.
