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However, the medication list, which was integrated into her discharge letter, did contain a potentially perilous spelling mistake (Figure 2), as was only later recognized during a routine medication chart review by the department's consultative clinical pharmacologist.
- Johannes Heck, Adrian Groh, Dirk O Stichtenoth, Stefan Bleich, Olaf Krause
- 2020
Oct 15, 2020 · In this article, we investigate three cases in which. confusion of look-alike/sound-alik e (LASA) drug names trig. gered medication errors with quite distinct outcomes. 2. CASE 1. An 80-year-old ...
Since 2008, the Institute for Safe Medication Practices (ISMP) has maintained a list of often confused drug names related to look-alike and sound-alike characteristics. 17 However, due to lack of standardization in the packaging of medications, an additional list of medication that are similar in appearance in the packaging is difficult to compile.
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Jun 15, 2017 · Background Recently, the Food and Drug Administration issued two Warning Letters to pharmaceutical companies for failing to fulfill product listing obligations for what appear to be oversights. In the first letter issued at the end of April, FDA said the lists of active ingredients in the product listing and in the product labeling did not match. The listing included an active ingredient not ...
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Did the medication list contain a spelling mistake?
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Jul 27, 2010 · Tall Man Lettering (TML) is the practice of writing part of a drug’s name in upper-case letters to help distinguish look-alike drugs from one another to avoid medication errors (Figure 1). For example, in TML, “prednisone” and “prednisolone” would be written “predniSONE” and “prednisoLONE” respectively (Tall Man letering, 2010).
