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Patient Safety Authority Releases Advisory Focusing on Common Causes of Medication Errors
Date:9/27/2007

Drug mix-ups occur frequently due to packaging and sound-alike drug names

HARRISBURG, Pa., Sept. 27 /PRNewswire-USNewswire/ -- Medication errors continue to rank high (23%) in the number of reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS). The Patient Safety Authority highlights the common causes of drug errors in its 2007 September Patient Safety Advisory.

Unclear and confusing labeling and packaging as well as look-alike or sound-alike drug names significantly contribute to medication errors, according to data received by the Authority.

"Ambiguous and confusing packaging and labeling contribute to medication errors," said John Clarke, MD, editor of the Patient Safety Advisory. "Errors can occur because healthcare practitioners become familiar with a certain package's appearance. When the package or label looks similar to that of another product, or is changed, practitioners may not realize the difference.

"Practitioners tend to see what is familiar rather than what is actually there. If a drug has distinctive packaging, the potential for mix-ups may be reduced," added Clarke. "Also, the more prominent parts of the label are not necessarily the ones with the most important information for those dispensing the medication."

Factors that relate to the medication's label or package that contribute to the errors include: problems with readability of labels, confusing expression of the drug's strength or concentration, over reliance on color as an identifier and lack of contrast or visibility for important label statements.

Michael Cohen, RPh, MS, ScD, president of the Institute for Safe Medication Practices, a subcontractor with the Patient Safety Authority, said drug packaging errors are nothing new.

"Although more and more pharmaceutical manufacturers take into account how practitioners actually identify and use their products, that has not always been the case," said Cohen. "Theref
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SOURCE Pennsylvania Patient Safety Authority
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