Methods of Avoiding the Errors in the first place

[Web Ferret]

An interesting development is "Tallman lettering".
This is being looked at for medicines safety.

So drug names on boxes, labels, your screen etc would be:

HumaLOG
HumaLIN

FLUoxetine
DULoxetine

oxyCODONE
OxyCONTIN



An internet search on tallman drugs or similar will find a lot of the research on this.

[DavidS]

Firstly, for Shan

To err is human, to forgive divine.
Alexander Pope, An Essay on Criticism
English poet & satirist (1688 - 1744)

and don't forget the second bit. It's the solution to the problem!

SECONDLY, I THINK YOU NEED TO BE CAREFUL WITH BLOCK
CAPITALS, BECAUSE I DON'T THINK THE BRAIN "READS" THEM AS
THOROUGHLY AS IT DOES LOWER CASE, AND IT CAN ALL
APPEAR TO BE A BIT OF A BLUR AFTER A WHILE,
PARTICULARLYIF YOURSPACINGISABITOUT.
I'VE USED ARIEL NARROW FOR THIS, WHICH NICELY
MAKE THE POINT. I'M A LITTLE TEAPOT SHORT AND
STOUT HOLD MY HANDLE NOT MY SPOUT OO ER

[medical6969]

The capiTAL letters are only for part of the word e.g. FLUOxetine. Im looking into the research as mentioned by WebFerret.

There seems to be two aspects to errors.
Firstly, the simple act of not seeing what is actually in front of you. So you have a box of propranolol in your hand and see it as prednisilone. This is called 'inattentional blindness' check out this article from the Institute of Safe Medicine Practices (ISMP) Inattentional blindness: What captures your attention?.



Secondly, the fact that you just dont know something e.g. you get a prescription for diclofenac 50mg E/C MR. I was never taught at university that such a preperation existed so I may just dispense the usual diclofenac tablets which I am familiar with, rather than the M/R preparation, without even realising its a mistake. This is called a blindspot i.e. information which other people know, but I dont know. Just like driving a car and pulling into the right hand lane, not seeing the car to your right, even though the driver in the right hand lane can see you.

I think it would be worthwhile to tackle this second aspect.

A list of drugs or situations which should cause you to automatically 'think'.
e.g. Methotrexate = Think...weekly dose
Diclofenac 50mg = Think...is it M/R or E/C or both
Peppermint oil 0.2ml = Think...is it M/R

Any thoughts?

[Web Ferret]

Like I said this is being researched as to is it any better than what we have now.
Its not definate.

[Mrs Pill]

We used to organise the Methadone cupboard into days of the week until an error occurred with a mispick of a name. Oh joy! Its now organised into surname order so that picking is a positive choice.

[Fleegle]

The capiTAL letters are only for part of the word e.g. FLUOxetine. Im looking into the research as mentioned by WebFerret.

There seems to be two aspects to errors.
Firstly, the simple act of not seeing what is actually in front of you. So you have a box of propranolol in your hand and see it as prednisilone. This is called 'inattentional blindness' check out this article from the Institute of Safe Medicine Practices (ISMP) Inattentional blindness: What captures your attention?.



Secondly, the fact that you just dont know something e.g. you get a prescription for diclofenac 50mg E/C MR. I was never taught at university that such a preperation existed so I may just dispense the usual diclofenac tablets which I am familiar with, rather than the M/R preparation, without even realising its a mistake. This is called a blindspot i.e. information which other people know, but I dont know. Just like driving a car and pulling into the right hand lane, not seeing the car to your right, even though the driver in the right hand lane can see you.

I think it would be worthwhile to tackle this second aspect.

A list of drugs or situations which should cause you to automatically 'think'.
e.g. Methotrexate = Think...weekly dose
Diclofenac 50mg = Think...is it M/R or E/C or both
Peppermint oil 0.2ml = Think...is it M/R

Any thoughts?

Your mis-spelling of 'prednisolone' horrifies me, and makes a mockery of your high-powered post. If you can't spell the name of the drug in the first place, how can you possibly be trusted to identify a potential error in prescribed similarly-named drugs?

Fleeg.

[Pharmanaut]

Your mis-spelling of 'prednisolone' horrifies me, and makes a mockery of your high-powered post. If you can't spell the name of the drug in the first place, how can you possibly be trusted to identify a potential error in prescribed similarly-named drugs?

Fleeg.

I seem to have read something in the NPSA guide to safer dispensing about 'tallman' drug names, similar to your posting.
Was it one of the PMR system reps that showed me a demo where they had done this with the drug names?
I found them very unusual to look at, with my eyes fixating all over the place in the short demo.
I guess there is no substitute for training yourself to "slow down" and read all of the drug name as if saying it aloud to yourself. In reality the "slow down" is just is of the order of a couple of hundred milliseconds anyway.

[medical6969]

Your mis-spelling of 'prednisolone' horrifies me, and makes a mockery of your high-powered post. If you can't spell the name of the drug in the first place, how can you possibly be trusted to identify a potential error in prescribed similarly-named drugs?

Fleeg.

Well spotted, however, I really don't think it makes a mockery of the rest of the post. Any way I'm not interested in bickering. I prefer to get things done. Considering that we are the last line of defence before medication reaches a patient it's surprising that so little posts have made within this section of the forum. I hope those who care about patient safety can work together to help us all to raise our ability to spot errors.

I for one am willing to sacrifice my time/effort/wealth and sweat to achieve this ... 'By any means necessary'.

To take this topic further.
I have corrected other pharmacists mistakes many times when it comes to quantity i.e. missing tablets. They don't seem to be opening the packs to ensure they are full. Is this a common trend with you guys? I can see in a busy pharmacy this may act like a low risk short cut to the checking procedure.

[Jeff]

To take this topic further.
I have corrected other pharmacists mistakes many times when it comes to quantity i.e. missing tablets. They don't seem to be opening the packs to ensure they are full. Is this a common trend with you guys? I can see in a busy pharmacy this may act like a low risk short cut to the checking procedure.

I very rarely check quantities. An error would be symptomatic of a failure in the system of adequately marking split packs.
I'd rather expend the effort of the system than the checking process.

[medical6969]

If I was working in my own pharmacy I would probably not check quantity as I would know with some degree of confidence that the box would be marked as split. However, as a locum pharmacist I would not have any reason to trust the robustness of their system.

99.9% of the time I open every single pack of medicine. Only if the pharmacy is extremely busy do I skip this step (with some unease). In hind sight this is very time consuming and probably makes me rush the rest of the checking procedure. I will consider changing my current practice.

I think there must be a distinction between whole packs e.g. a pack of 28 Atenolol ... and a box that is meant to contain 32 Prednisolone. If something is meant to be added or taken away from the pack then you would definitely check it...right? Many times dispensary staff have presented me with boxes of medicines with incorrect quantities when they were meant to add or subtract an amount.