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becoming comfortable with our humanity

By Dennis Tribble posted 08-12-2016 09:24


I just finished reading a very interesting article about the correlation of performance on some specific human cognition laboratory tests with the tendency to confuse look-allike-sound-alike (LASA) drug names. What got me excited was that the research actually investigated specific cognitive issues:

  • how easily a drug name was read and remembered
  • how easily a drug name was heard and remembered
  • how easily a drug name was read and remembered after performing another cognitive tasks (doing a math problem)
  • how often the drug name was properly distinguished in contrast to another drug name in a known LASA pair

The study involved 80 participants who were, in equal measures, physicians, nurses, pharmacist, [pharmacy] technicians and non-healthcare-professionals. The measurements were sufficiently detailed that they could even measure how long it took someone to remember the drug name (whether they remembered it correctly or incorrectly), how long it took them to distinguish between the options in the LASA pairs (whether they selected the correct item or not), and how often they "hovered" over the wrong LASA name before ultimately selecting the correct name (considered a near miss).

I was excited to learn that performance on each of theses tests positively correlated with the likelihood of being involved in a dispensing error. Indeed, even longer times trying to successfully remember a drug name, or trying to distinguish between a pair of LASA names was predictive. So was a higher "near miss" rate.

I was excited because it appears that we are finally building up a fund of science that should permit us to better design drug names. That excitement is tempered by my perception that the fund of useful drug names may be diminished.

Our bigger problem, IMO, is that our primary tool for distinguishing LASA names (Tall-man lettering) has its own limits. I distinctly remember a fracas at a safety meeting a decade ago in which a company roundly chastised the FDA for not permitting them to use Tall-man lettering EPI on their epirubicin product. It must have escaped their notice that EPI was already in use for epinephrine! Perhaps testing like this could permit us to more scientifically apply our limited selection of Tall-man lettering to the drug names that really need it.

More to the point, however, I was excited to see us sufficiently comfortable with our basic humanity (and our human failings) to expose it, to study it scientifically, and to start thinking about how we could use our understanding of it to better tool ourselves to a higher level of quality. It gave me hope that we might be on our way to abandoning our illusion of our capacity for perfection. And that, colleagues and friends, is a step toward providing our patients the quality and safety of medical care they deserve.

What do you think?


Dennis A. Tribble, Pharm. D., FASHP

Ormond Beach, FL

The opinions expressed herein are my own, and not those of my employer nor of ASHP

#MedicationSafetyOfficers #MedicationSafety #Informaticists
1 comment



08-12-2016 10:03

I agree Dennis. We are overdue to apply more science to the naming of new drugs. No system will ever be perfect, but this would be a good step forward.