Author Biographies
Myungsun Ro, PharmD, MS, Data Science and Research, Patient Safety Authority
Myungsun (Sunny) Ro (mro@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority (PSA). Her responsibilities include analyzing and synthesizing data from various sources to identify opportunities to improve patient safety, as well as writing scientific articles for publication in the PSA’s peer-reviewed journal, Patient Safety.
*Corresponding author
Rebecca Jones, MBA, RN, Data Science and Research, Patient Safety Authority
Rebecca Jones is director of Data Science & Research at the Patient Safety Authority.
ABSTRACT
Background
Medication errors represent a significant challenge to patient safety. Wrong drug events (WDEs), which occur when a patient receives a medication different from the one intended, can cause serious patient harm.
Methods
We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for wrong drug medication error reports submitted in calendar year 2023 to identify WDEs that reached the patient in which one medication was inadvertently ordered, dispensed, or administered in place of another medication that contained a different active ingredient.
Results
We identified and analyzed 450 WDE reports from 127 different healthcare facilities. Insulin was the most frequently reported medication class, comprising 10.3% (93 of 900) of all reported medications involved in a WDE, followed by antibacterial for systemic use (n=90), electrolyte solution (n=62), and opioid (n=51). Many WDEs occurred within the same medication class, highlighting their shared stem names.
Conclusion
WDEs can cause serious patient harm resulting from omission or delay of a necessary medication, administration of an unintended and/or contraindicated medication, or other deviation due to confusion between two medications. Medications belonging to the same class, as well as those sharing similar names, require heightened attention. Additional research regarding the contributing factors to WDEs could provide a more complete understanding of these events and facilitate further development of evidence-based, targeted prevention strategies.
Plain Language Summary
It’s easy to mix up names, like say “sucrose” and “sucralose”—the first is commonly called sugar, and the second is an artificial sweetener better known by its brand name, Splenda. Confusing ingredients while baking is usually a harmless mistake, but if you confuse medications, for example Premarin (used to treat symptoms of menopause) and permethrin (used to treat lice), there could be a serious problem. This type of medication error is considered a wrong drug event (WDE), in which a patient receives a medication different from the one intended. WDEs can result in patient harm from missing or delaying needed medication; administering an unnecessary or contraindicated medication; or administering a medication in other incorrect ways, such as wrong route and dose.
One major contributing factor to WDEs is confused drug names, involving those that are similar in how they are spoken or written—known as “look-alike, sound-alike” medications. This can occur with generic names (e.g., azithromycin, clarithromycin, and erythromycin), brand names (e.g., Solu-Cortef and Solu-Medrol), abbreviations (e.g., TPA and TNK), or any combination thereof. In this study, researchers analyzed patient safety event reports from the Pennsylvania Patient Safety Reporting System and identified the individual specific medications, pairs, and classes most frequently involved in WDEs and summarized the serious events that resulted in patient harm. Their work highlights the importance of giving close attention to medications with similar names, particularly those within the same medication class that share the same stem, such as “phrine” as in epinephrine and norepinephrine.
