Abstract
Objective
Look-alike, sound-alike (LASA) drug name substitution errors in children may pose
potentially severe consequences. Our objective was to determine the degree of potential
harm pediatricians ascribe to specific ambulatory LASA drug substitution errors.
Methods
We developed a unified list of LASA pairs from published sources, removing selected
drugs on the basis of preparation type (eg, injectable drugs). Using a modified Delphi
method over 3 rounds, 38 practicing pediatricians estimated degree of potential harm
that might occur should a patient receive the delivered drug in error and the degree
of potential harm that might occur from not receiving the intended drug.
Results
We identified 3550 published LASA drug pairs. A total of 1834 pairs were retained
for the Delphi surveys, and 608 drug pairs were retained for round 3. Final scoring
demonstrated that participants were able to identify pairs where the substitutions
represented high risk of harm for receiving the delivered drug in error (eg, did not
receive methylphenidate/received methadone), high risk of harm for not receiving the
intended drug (eg, did not receive furosemide/received fosinopril), and pairs where
the potential harm was high from not receiving the intended drug and from erroneously
receiving the delivered drug (eg, did not receive albuterol/received labetalol).
Conclusions
Pediatricians have identified LASA drug substitutions that pose a high potential risk
of harm to children. These results will allow future efforts to prioritize pediatric
LASA errors that can be screened prospectively in outpatient pharmacies.
Keywords
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Article Info
Publication History
Published online: July 18, 2015
Accepted:
June 25,
2015
Received:
November 1,
2013
Footnotes
The authors declare that they have no conflict of interest.
Identification
Copyright
© 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
