I’ve Been Thinking about patient names, drug names, look-alikes, and sound-alikes.

CLOSE IS NOT GOOD ENOUGH

I’ve been thinking…about patient names, drug names, look-alikes, and sound-alikes.

A few years ago, a charity mistakenly channeled my donations into the account of another donor named Mark Neuenschwander. One evening a United gate agent called me over the PA but was looking for another traveler with the same name. Not long ago, a greeting card showed up in the mail, addressed to yours truly, expressing congratulations on the arrival of a new baby—long after my five kids were grown and gone. Then there was the time an overseas client Googled my name and assumed that I moonlighted as a mean bass player doing gigs in Tampa. Hilarious, harmless mix-ups.

However, a few years ago, my uncle, David N. Neuenschwander, was heading for surgery when his wife noticed the chart accompanying him read David J. Neuenschwander. Obviously, someone made a transcription error with his middle initial. Wrong. Someone made the mistake of grabbing another patient’s chart. It was close but no cigar. What are the odds? High enough that I’m not going to assume they have the right Mark Neuenschwander when it’s my time to go under the knife. “Yes, I am Mark Neuenschwander. Could you please scan my barcode to make sure I am the right one?”

Well, that takes care of the first right. What about the second? We’ve identified the right patient. How about identifying the right drug in a sea of spelled-alikes?

Apaprenlty, the oredr of the ltteers in a wrod deosn’t raelly matetr that mcuh. The olny iprmoatnt tihng is taht the frist and lsat ltteer be in the rghit pclae. The rset can be a tatol mses and you can sitll raed it wtih lttile porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Amzanig!

The above paragraph, lifted from the Internet, shows how we are capable of seeing the right word even when its letters are in the wrong order. However, we are also capable of seeing the wrong word when its letters are in the right order—which can spell trouble when it comes to the medication-use process. Consider this short list of troublesome drugs:

Advicor vs. Altocor
Cedax vs. Cdex
Dioval vs. Diovan
Diovan vs. Darvon
Dobutamine vs. Dopamine
Epinephrine vs. Ephedrine
Foltx vs. Folex
Novolin 70/30 vs. Novolog Mix70/30
Percocet vs. Procet
Plantinol vs. Pantanol
Retrovir vs. Ritonavir
Tobrex vs. Tobradex
Vinblastine vs. Vincristine
Zantac vs. Zyrtec

Notice how often not only the first and last letters but also the first and last syllables are the same. Obviously, close is not good enough.
There is no substitute for caregivers carefully reading the names on all drugs they handle—using reading glasses and looking them up in a drug database, if necessary. But that, in my opinion is not enough. Redundant checking with bar-code scanning helps pharmacists, technicians, and nurses avoid mix-ups and misadventures.

Bar-code verification really should occur at all critical points of medication distribution, dispensing, and administration. Technicians should scan bar codes on medication packages when stocking, removing, and returning drugs to patient cassettes and picking bins. Pill bottles and the dispensing cassettes into which their contents are poured should be scanned for a match when operators are stocking automated packaging machines. Up on the wards, medications should be scanned when they are placed in or pulled from automated dispensing cabinets. And above all, each patient and medication should be scanned to verify that the caregiver has the right dose of the right drug for the right patient at the right time.

Meanwhile, I’m considering taking bass lessons.

What do you think?

Mark Neuenschwander

mark@hospitalrx.com

Copyright 2007 The Neuenschwander Company