RT Journal Article
SR Electronic
T1 Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains
JF BMJ Quality & Safety
JO BMJ Qual Saf
FD BMJ Publishing Group Ltd
SP 395
OP 407
DO 10.1136/bmjqs-2015-005099
VO 26
IS 5
A1 Scott R Schroeder
A1 Meghan M Salomon
A1 William L Galanter
A1 Gordon D Schiff
A1 Allen J Vaida
A1 Michael J Gaunt
A1 Michelle L Bryson
A1 Christine Rash
A1 Suzanne Falck
A1 Bruce L Lambert
YR 2017
UL http://qualitysafety.bmj.com/content/26/5/395.abstract
AB Background Drug name confusion is a common type of medication error and a persistent threat to patient safety. In the USA, roughly one per thousand prescriptions results in the wrong drug being filled, and most of these errors involve drug names that look or sound alike. Prior to approval, drug names undergo a variety of tests to assess their potential for confusability, but none of these preapproval tests has been shown to predict real-world error rates.Objectives We conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates.Methods Eighty participants, comprising doctors, nurses, pharmacists, technicians and lay people, completed a battery of laboratory tests assessing visual perception, auditory perception and short-term memory of look-alike and sound-alike drug name pairs (eg, hydroxyzine/hydralazine).Results Laboratory test error rates (and other metrics) significantly predicted real-world error rates obtained from a large, outpatient pharmacy chain, with the best-fitting model accounting for 37% of the variance in real-world error rates. Cross-validation analyses confirmed these results, showing that the laboratory tests also predicted errors from a second pharmacy chain, with 45% of the variance being explained by the laboratory test data.Conclusions Across two distinct pharmacy chains, there is a strong and significant association between drug name confusion error rates observed in the real world and those observed in laboratory-based tests of memory and perception. Regulators and drug companies seeking a validated preapproval method for identifying confusing drug names ought to consider using these simple tests. By using a standard battery of memory and perception tests, it should be possible to reduce the number of confusing look-alike and sound-alike drug name pairs that reach the market, which will help protect patients from potentially harmful medication errors.