Look-Alike, Sound-Alike: A Common Cause of Medication Errors

Pharmacy folks, like many others, turn to social media to express frustration with their job. One of the more common photos posted these days shows a prescription with a plea for help from the public to interpret the name of a prescription item … "what in the world is the name of this drug?" Answers may range from humorous to slightly off-color, but the overall consensus is that sometimes it's hard to be 100% sure. What is clear, however, is that handwriting and other factors often contribute to confusion around drug names that look and sound similar. These drugs are also known as "look-alike, sound-alike" medication pairs (LASA). When confusing labels are paired with a high stress work environment with many distractions, errors are bound to occur.

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A study completed by the Food and Drug Administration (FDA) evaluated common causes of errors related to medication. This study found the most common type of fatal medication error was improper dose (41%), and the second most common type of error was related to wrong drug and wrong route of medication (16% each). It is clear that labeling is an important part of medication safety. How can pharmacy technicians play a role in reducing the risk of medication errors and minimize patient harm, particularly involving drug names?

The Prescription Label: It All Starts Here

The pharmacy technician is often the first staff member to receive and interpret the prescription label, and can pause the process if any information is missing or includes an error. For example, although not all states require the prescriber to list the purpose the patient is taking a medication (also known as the "indication"), inclusion of this information can serve as a "red flag" if the wrong medication has been chosen. Sometimes this information may simply be vague, such as "Take <blood pressure medication> for heart health", but other times the indication may be completely incorrect, such as "Take <cholesterol medication> for infection." These types of inconsistencies may require the pharmacist or another staff member to call the prescriber's office to clarify the prescription. If possible, the technician should also refer to the patient's medical record to confirm the prescription diagnosis matches a health condition included in the patient's chart. Any inconsistencies should be discussed with the supervising pharmacist immediately.

Safety Must Always Come First

Unfortunately, not all prescribers or their nursing staff may want to receive these types of calls, but patient health and safety must come first. If the pharmacy staff member does speak to a provider or team member to clarify the prescription, it is also good practice to confirm that the label contains both the brand name (trade name) and generic (nonproprietary) name for the medication. Errors can also happen due to poor handwriting, use of abbreviations, memory lapse, rushed work environment, and/or large formularies from which to choose therapies. Attempts should also be made to minimize the use of verbal and telephone orders which are more difficult to verify should confusion occur. Written orders allow for the pharmacy team to verify the order at the time of dispensing, and in future situations should questions arise.

An additional strategy technicians can employ is to become aware of some common examples of medications that have similar names. Examples are published each year by the Institute for Safe Medication Practices (ISMP) and include the following:

  • Acetaminophen and acetaZOLAMIDE
  • Hydralazine and Hydroxyzine
  • amantadine and amiodarone
  • buPROPion and busPIRone
  • CeleXA and ZyPREXA
  • clonazePAM and cloZAPine
  • cloNIDine and clonazePAM

Some of the examples listed above also demonstrate a risk management technique known as "tall man" lettering (also known as mixed-case), i.e. changing the appearance of look-alike product names to bring attention to spelling dissimilarities. Other options for drug labeling including boldface or color differences. Some pharmacy dispensing software systems are even configured such that the screen prevents look-alike drug names from appearing in consecutive order. Very creative!

Other Strategies to Reduce Errors

Pharmacy technicians can also help reduce medication errors related to drug names by working to create an organized medication storage environment. For example, technicians can place "eye-catching" labels on storage bins and store medications that could potentially be mixed up in different areas of the pharmacy. Some software programs may incorporate bar code technology to confirm the correct product has been chosen for each prescription. In addition, technicians can also ask their supervising pharmacist to counsel patients who are taking medications with problematic drug names. The pharmacist can also provide written information to further reduce errors that could occur after the correct medication is dispensed and taken home with the customer. As a team, the pharmacist and technician can help get the right medication to the right patient and reduce medication errors.

Dr. Michelle Lamb

Your Call is Important to Us: How Pharmacy Techs Can Stay Sane Amidst Chaos

The sounds of the pharmacy ring loud and clear. Spatulas counting tablets by fives, the ring of the drive-through bell, pill bottles returned to shelves, and (of course) the phone. The DARN phone, it NEVER stops! Pharmacy technicians must balance customer needs, dispensing duties, inventory management, and their own mental health. Often the sound of the phone ringing seems like just enough to fry that last nerve. Even the renowned "super tech" may struggle to stay sane while managing so many roles, and just when you feel caught up the pharmacist hollers to answer the phone. OUCH! It's time to make an important choice – do you tell the pharmacist you are busy, answer the phone and lose track of which refill you were processing, or perhaps (in a not so subtle but effective move) throw the phone into the returns bin and find a new line of work?

High Expectations and Strong Emotions

Providing excellent customer service during a pandemic is not easy! Extra phone calls related to COVID testing or hand sanitizer may cause stress levels to soar. The Centers for Disease Control offer some tips to help healthcare personnel cope and stay resilient. These suggestions include the following:

1. Communicate openly with colleagues about job stress, and work together to find solutions.

2. Remember everyone is in an unusual situation with limited resources.

3. Realize there are work factors that you have no control over.

4. Recognize that you are providing a crucial role in fighting the pandemic and doing the best you can with what you have available.

Overwhelmed technicians may also communicate with their pharmacist about ways to reduce the stress associated with the busy environment, including rotation of job roles and assignment of job responsibilities, such as answering the phone. Hopefully, the pharmacist will listen and respond.

RELATED: Crunching Numbers: How Pharmacy Techs Can Keep It All Straight

Slowing Down During Operation Warp Speed

Although it is a reasonable first effort, communication strategies may ultimately have little effect on the business of retail pharmacy. The overwhelmed pharmacy technician can also reach for coping strategies that can be done anytime, and which will support their mental health. Here are some simple ideas for staying calm while the script count never slows. First, consider designating a one-minute mental break at the top of each hour. This could look like taking a series of deep breaths, or a simple exercise such as leaning over and touching your toes. Another option could be each time you look out a window and see a cloud, wait a few moments until you see the cloud move before resuming activities. These brief moments of calm may sound silly or unnecessary, but a few seconds to periodically perform self-care can lower stress.

But That Phone Is Still Ringing!

Despite improved communication with the pharmacist and stealing a moment to slow your heart rate and thoughts, ultimately the pharmacy work environment is shaped by the duties that are required by the pharmacist. This is particularly true for the tasks that can only be completed by a pharmacist, and they are responsible for everything that happens in the pharmacy! It may appear as though they are simply staring at a screen or answering questions about the latest drug to be featured in a commercial. However, their responsibilities include double-checking all prescriptions before it is sold to a patient, ensuring all prescriptions are legal and valid, adhering to all state and federal regulations, keeping accurate records, and paying close attention to detail. Unlike a pharmacy technician, there is no higher-level professional to check the pharmacist's work, and mistakes can have grave consequences.

Although it isn't necessarily noticed by technicians or customers, pharmacists may perform their final check with a series of "rights" while verifying the prescription: it is critical that the right dose of the right drug reaches the right patient at the right time via the right route. Unfortunately, the truth is that from the pharmacist perspective, the ringing phone represents an interruption to this thought process, which could result in having to restart the verification. If the pharm tech is able to answer (and screen!) all phone calls that do not directly require the pharmacist knowledge, then the pharmacist is able to focus on those activities that do require the additional clinical knowledge and resources that were obtained through a doctorate level of education. Other tasks that may be required to be completed by a pharmacist include inventory of controlled drugs and supervising or training of student interns and other personnel.

RELATED: What is the Difference Between a Pharmacy Technician and a Pharmacist?

But Does Team Work Make the Dream Work?

The hard truth is sometimes it does, and sometimes it doesn't. The pharmacist and pharm tech can accomplish the most when working together – like how the right hand helps the left. But when it comes down to it…it's probably the hand of the pharmacy technician that answers most calls. Take a deep breath…you got this!

Dr. Michelle Lamb

Crunching Numbers: How Pharmacy Techs Can Keep It All Straight

Pharmacy technicians are counting machines! OK, not literally counting machines (which some stores are actually lucky enough to have), but they do count a variety of items throughout the day. How many customers were in the drive-through before opening? How many refills in the queue? And perhaps the most important…how many minutes until closing time? Counting counts for so much, and there are certain reminders that are worth revisiting, starting at the beginning…with zero.

Zero In On This Idea

Believe it or not, there are many ways to express the number zero! The British use the term "naught" but in the United States other options include aught, cipher, goose egg, nil, nothing, zilch, and zip. However one chooses to describe zero around the world, pharmacy personnel must honor the concept of "leading" and "trailing" zeroes. A leading zero is a zero preceding a decimal point, such as Risperdal 0.5 mg PO daily. Leading zeroes must always be used when writing prescriptions for quantities of drugs that are fractions of a unit to avoid dosing confusion. For example, if the prescription above is written without the leading zero, i.e. Risperdal .5 mg PO daily, the result may be a tenfold dosing error! Pharmacy technicians that encounter a prescription written incorrectly should notify their supervisor of the need to clarify the drug strength.

On the other side of this concept is a "trailing" zero. A trailing zero refers to a zero that follows a decimal point, such as Clonidine 1.0 mg PO TID. Using a zero after a decimal point can also result in a tenfold dosing error if the decimal point is illegible or not noticed. For this reason, the Joint Commission on the Accreditation of Hospitals has included trailing zeroes on their official "Do Not Use" list.

Other Number Confusion – Where to Start?

Another topic in pharmacy where confusion may come up are with starter packs. A starter pack refers to a unique manufacturing package size for medication regimens with quantities that may increase during the first few days or weeks of use. Examples of starter packs include the following regimens:

  • Chantix (Varenicline): The patient should take one 0.5 mg tablet PO for 3 days, then one 0.5 mg tablet PO BID for 4 days. Continued treatment is 1 mg PO BID. The dose is started slowly to reduce adverse effects with varenicline, including strange dreams and trouble sleeping.
  • Namenda (Memantine):
    • Week 1 (day 1-7): The patient should take one 5 mg tablet PO daily for 7 days.
    • Week 2 (day 8-14): The patient should take one 10 mg tablet per day for 7 days.
    • Week 3 (day 15-21): The patient should take one 15 mg tablet per day for 7 days.
    • Week 4 (day 22-28): The patient should take one 20 mg tablet per day for 7 days.
    • The maintenance dose is 20 mg per day. Each tablet strength is a different color, and starting with lower doses reduces the risk of side effects such as headache and sleepiness.
  • Xarelto (Rivaroxaban): This starter pack is designed for the first 30 day supply. The patient should take 15 mg PO BID for 21 days, then the dose is reduced to 20 mg PO daily. Higher doses are given at the start of treatment when the patient is most vulnerable to a clotting event such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
  • Lamictal (Lamotrigine): This medication has not one, but THREE different types of starter kits, each based upon other medications taken by the patient. The starter kits help minimize drug interactions, including life-threatening rashes.
    • Blue starter kit: for patients taking valproate
    • Green starter kit: for patients taking carbamazepine, phenytoin, phenobarbital, or primidone
    • Orange starter kit: for patients NOT TAKING carbamazepine, phenytoin, phenobarbital, primidone, or valproate

Take extra precaution when entering prescriptions for starter kits and ensure that you pick the right packaging and kit choice, and confirm the patient has received counseling from the pharmacist on how to use these kits to prevent errors related to patients who do not take these items as prescribed.

RELATED: 3 Ways Pharmacy Technicians Are Vital for Patient Care

Billing and Other Considerations

A final consideration when entering and filling prescriptions are errors related to the package size itself and how these items are billed to insurance. Stock bottles often come in quantities of 90 or 100, but there are some exceptions. Tizanidine products, for example, often contain 150 tablets per stock bottle (not 100) which can increase the risk of error when pouring an entire bottle into a vial. Other examples include testosterone gel packets supplied in boxes of 30 packets but billed for a quantity of 150 grams, and birth control packets which may have 21, 28, or 91 tablets.

The bottom line is take your time and focus on the details!

Dr. Michelle Lamb

Facing the Pandemic: “Unmasking” Tips and Tricks for Pharmacy Technicians

Let's face it, folks, no matter how you look at it 2020 has been a tough year. Much about the pandemic is unknown and may remain that way for quite some time, but one certainty is the impact that wearing a mask and social distancing can have upon transmission of COVID-19. What is less clear is the impact masks and physical separation have on effective communication within the pharmacy. Keep reading for some real-world tips to improve these situations.

The pharmacy environment is a bustling and often stressful workplace, and in current times customers may be in an even bigger hurry to grab their medications and hit the road. Despite this, it remains important for the pharmacy technician to communicate with patients and customers in a clear and precise manner even while wearing a mask and social distancing. Being mindful of certain tips and tricks can help reduce communication errors, clarify nonverbal messages, and avoid facial irritation or "maskne" caused by long shifts wearing a mask.

RELATED: Working as a Pharmacy Technician

"Excuse Me, But What Did You Just Say?"

Since masks can muffle sound, and speech becomes quieter with distance, it is tougher than ever for pharmacy technicians to effectively relay prescription or health information to customers. For example, technicians providing price quotes to customers for a medication or co-pay may use the word "fifteen" as in, "Your new prescription has a $15 co-pay." This amount may be misheard as "fifty" instead, which would certainly cause some stress for all involved. One tip when sharing numerical information with a customer is to use multiple ways to state a quantity, such as "That will be fifteen dollars, one-five" or "Your prescription's instructions read forty units of insulin, four-zero." Pharmacy technicians can further improve communication by facing the customer directly, speaking louder and slower, and moving to a quiet counseling area if possible.

The Eyebrows Tell a Story

Masks affect our ability to see each other's facial expressions and can impact our understanding of what we are hearing. On the other hand, thoughtful use of hand gestures and body language can send a strong message of customer service and empathy. For example, pharmacy technicians should aim to relax their shoulders (not always easy), try not to cross their arms in front of their body, and nod to acknowledge listening and understanding of pharmacy customer concerns. In addition, eyebrows tell the story! Raised eyebrows imply happiness, pinched eyebrows can mean sadness, and "V" shaped eyebrows often connote anger or frustration. In addition to careful nonverbal communication, the pharmacy team should consider removing physical barriers that could impede the travel of sound or block customer view, such as over the counter (OTC) item displays or other signage. The Hearing, Speech, and Deaf Center even provides options for making or purchasing clear masks, an excellent option for team members working with deaf or hard of hearing customers who may rely on lip-reading.

2020 and Beyond…What's Next?

Some jobs just aren't meant for working from home, and most pharmacy personnel will not have the option to work in pajamas and forgo makeup or deodorant for a day. If working retail during a pandemic wasn't stressful enough, now pharmacy technicians must also deal with a certain type of acne associated with facial coverings, affectionately known as "maskne." That's right, there's even a nickname for this condition brought to us by 2020. This type of skin outbreak is actually called "acne mechanica," and it is caused by pores that become blocked by sweat, makeup, dirt, or oil. Before the pandemic, this condition was commonly found among athletes who were required to wear sports gear with helmets or straps, or on the armpits of patients using crutches.

These days, the friction of wearing a mask for long periods of time can clog pores, and the mask itself can lead to increased humidity and further exacerbate outbreaks. Strategies to help reduce the risk or severity of acne associated with wearing a mask include washing cloth masks daily and replacing disposable masks often. If an outbreak should occur, it is not uncommon to scrub excessively or too hard, which can actually worsen an outbreak. Instead, it is recommended to wash with a gentle facial cleanser and avoid products that are overly drying. Lotions that contain hyaluronic acid can also help keep skin moist, and products containing ceramides may provide a healthy protective barrier between the mask and the skin.

Don't forget to give your face a rest and remove your mask when it’s safe to do so, such as while driving or at home, unless taking care of a loved one and needing to take precautions. Take care of your face, and yourself! We can do this together.

Dr. Michelle Lamb