TELEPHONE ORDERS
Fifteen or fifty?
A medical resident ordered 50 units of insulin glargine, a long-acting human insulin analog, for a pediatric patient with diabetic ketoacidosis after discussing the patient's treatment plan with an endocrinologist. Normally, maximum doses are set at 0.5 units per kg at this hospital. The child weighed 48 kg, so the expected maximum dose would be only 24 units. A pharmacist confirmed the high dose with the resident. Later, the pharmacist saw the resident, who happened to say that the endocrinologist had seemed tired when they spoke on the phone. The pharmacist then checked the endocrinologist's note in the patient's electronic health record and saw a plan to possibly start insulin glargine 20 units. When the pharmacist asked the resident to again verify the dose, the endocrinologist said he had actually ordered 15 units, not 50 units, during the phone consultation with the resident.
When oral communications are necessary, the listener might misunderstand the information being communicated. Masks and/or face shields worn during the COVID-19 pandemic can further muffle sounds, which adds to the risk of mishearing. Taking these precautions could help prevent this type of error:
* When safe to do so, remove the mask and/or face shield when speaking by phone.
* For medication doses in the teens, state the dose the way pilots state numbers; for example, "15 units" should be stated as "one-five units." Stating each digit separately may also clarify other double-digit doses, such as 30, 40, 50, and so forth.
* Always follow through with readback: The listener documents what is heard, then reads it back to the speaker to make sure that the order was heard and transcribed correctly.
* Question and confirm any prescribed dosage that is outside recommended parameters.
GENERIC PAIR MIX-UP
Similar labels invite confusion
When putting away an order of medications, a pharmacy technician noticed nearly identical cartons of unit dose 50 mg tablets of hydrALAZINE, an antihypertensive, and hydrOXYzine, an antianxiety agent, from Major Pharmaceuticals (see photo below). Although the drug names on the carton labels incorporate tall man lettering, the rest of the letters in the drug names and formulations (such as "hydrochloride tablets") are presented in all uppercase letters, lessening the desired impact of the tall man letters. The prominence of "hydrochloride" in uppercase letters, listed on a separate line and spelled out (rather than abbreviated as HCl on the same line as the drug name), draws attention away from the drug name and adds to the similarity. In addition, the 50 mg strength is displayed on both boxes with the same background and format.
Confusing hydrOXYzine and hydrALAZINE is one of the most common generic pair mix-ups. With alphabetically similar names, the products are often stored next to one another on pharmacy shelves. Similar dosage strengths (10, 25, 50, and 100 mg), tablet formulations, and adjacent presentation in drop-down menus and picklists also contribute to mix-ups.
Some manufacturers use design strategies to make the tall man letters stand out; for example, by using different colors for the font and background as shown in the example below.
To prevent mix-ups between hydrOXYzine and hydrALAZINE, pharmacies should employ bar code scanning when these products are received and stored. Pharmacies should also consider distinguishing the unique characters in each name by circling them with a pen or purchase one of these products from a different manufacturer to further differentiate their appearance. By scanning bar codes before administering drugs, nurses help prevent this type of error.