New York Eye and Ear Infirmary
Adjust: Text Size Make Font Smaller Make Font Larger Print this Page: Normal Print Friendly Large Print Friendly Accessibility Info

E-Petition to Eliminate Ophthalmic Look Alike Sound Alike Medication Errors

Sponsored by The American Association of Eye and Ear Centers of Excellence (AAEECE), formerly The American Association of Eye and Ear Hospitals (AAEEH)
*Supported by:
The Institute for Safe Medication Practices
(ISMP)
American Society of Ophthalmic Registered Nurses (ASORN)
The American Pharmacists Association (APhA)

PA State Nurses Association (PSNA)
The American Society of Health-System Pharmacists (ASHP)
The World Association of Eye Hospitals (WAEH)

The National Community Pharmacists Association (NCPA)
The Association of periOperative Registered Nurses (AORN)
European Association of Hospital Pharmacists (EAHP)

E-Petition News

  1. October 4, 2013: LASA ALERT: New Labeling and Colors for Bausch and Lomb Eye Drop Bottles and Boxes:

    It seems that (no notification sent out from manufacturer to hospitals) Bausch and Lomb has changed their color coding system for their ophthalmic bottles and boxes (which you will see below) that  do not ALL comply with the American Academy of Ophthalmologists color-coding guidelines for Ophthalmic Medication Bottles by therapeutic classes.

    As you will see in the pictures below, some of the products are even more difficult to recognize now than before  (ex. given that some bottles of different therapeutic classes now only have white caps or have similar looking boxes).

    ***Please check all eye med labels/boxes/bottles 3 times as these new bottles have the potential for causing Look Alike Sound Alike (LASA)  Medication Errors.

    REMEMBER… RL3= read the label 3x:

    First, against the physician prescription/medication order,  again after you have entered the order and generated the label, and again prior to dispensing/ (or administering the med if you are a nurse or physician).***

    Please take a look at the new B&L Boxes and Bottles Photos below:

    Picture 1: Inconsistencies with AAO color code system:

    1. *Tobramycin: The Anti Infective cap should be Tan like the stripe on its box but instead it is colored WHITE,
    2. THEN we see that they have colored the other Anti-infective, Ofloxacin Solution, Cap TAN (like stripe on box) as per AAO guidelines?

    Inconsistencies with AAO color code system      

    THEN BELOW:

    Picture 2: Inconsistencies with AAO color code system:

    1. NSAID Flurbiprofen .03% Solution first bottle (Note AAO GREY color stripe on box for NSAIDs) but the Cap is WHITE  (should be Grey)
    2. And Tetracaine is an Anesthetic but the box stripe is Light Blue like beta blocker AAO Color  and the Cap is WHITE again?           

    Inconsistencies with AAO color code system

    ALSO LOOK how similar ALL  of the Bottles below look (fonts, label, colors, logos etc.,) even though different therapeutic classes:

    First pic=                                          Second Pic =
    Anti-infective, Steroid, Steroid       Anti-infective, Steroid, Steroid, Anesthetic

    First pic=Anti-infective, Steroid, Steroid ) Anti-infective, Steroid, Steroid, Anesthetic

    FYI:
    The chart below also lists examples of some other manufacturers of ophthalmic bottles which have used color coding systems different from the AAO color coding guidelines for eye drops:

    Class AAO                                         Color Recommendation   
    Anti-Infective                                             Tan
    *Product and Company/Cap Color below*
    Gentamicin 0.3% (Falcon) - white
    Gentamicin 0.3% (Pacific Pharma) - white
    Polymixin/Trimethoprim (B&L) - clear,colorless
    Tobramycin 0.3% (Falcon) - white
    AzaSite 1% (Inspire) - white
    Trifluridine 1% (Falcon) - white
    Anti-infectives Tan
    Viroptic 1% (Monarch) - clear, colorless

    Anti-inflammatories -  steroids                   Pink
    *Product and Company/Cap Color below*
    Durezol 0.05% (Alcon) - white
    Fluoromethalone 0.1% (Pacific Pharma) - white
    FML 0.1% (Allergan) - white
    Pred-Forte 1% (Allergan) - white
    Dexamethasone 0.1% (B&L) - white

    Beta-Blockers                                          Yellow
    *Product and Company/Cap Color below*
    Betoptic S 0.25% (Alcon) - light blue
    Timolol 0.25% (Falcon) - light blue

    Thank you and remember to RL3 (READ LABELS 3 TIMES).   

  2. April 26, 2012: ASHP BLOG UPDATE:  Here  is the link to our updated LASA SURVEY ASHP Blog page:  http://connect.ashp.org/ASHP/Blogs/ViewBlogs/?BlogKey=b28dbb73-3098-45ee-9cc0-28d8fa1724f3

  3. March 22, 2012: New Medication Errors/Incident Survey Involving LASA Eye and Ear Medication Errors posted on ASHP Connections Blog site: http://connect.ashp.org/ASHP/Blogs/ViewBlogs/?BlogKey=ba0a5449-1baf-4e5d-bc0c-a3450368a3ff

  4. March 19, 2012: Continuum Health Partners asks for  survey assistance:
    Connections

    MARCH 19, 2012
    This Week's Headlines

    Join New Safety Initiative Survey

    Continuum employees can assist the American Association of Eye and Ear Centers of Excellence (AAEECE) Worldwide Patient Safety Initiative to Address Look-Alike, Sound-Alike Eye-and Ear-Related Medication Errors.

    By taking a short survey, you can help AAEECE collect data on medication errors and incidents caused by sound-alike names, look-alike packaging, small lettering, similar looking bottles or colors, or any other packaging or lettering-related issues.

    “Our goal is to share this anonymous data with physicians, health care organizations, manufacturers of ophthalmic and otic products, and the FDA to highlight the effects of look-alike, sound-alike errors and to consider possible solutions,” says William Stratis, BSc, PharmD, RPh, NYEE Director of Pharmacy Services and Pharmacy Co-Chairman of the project.

    Please go to http://www.surveymonkey.com/s/7FVF5T7 to take the eight-question, multiple-choice survey, which takes less than three minutes to complete.

  5. March 15, 2012:  The American Academy of Ophthalmology’s Washington Report Express  asks AAO members and colleagues to assist the AAEECE Worldwide Patient Safety Initiative to Address Eye and Ear Medication Errors by completing a new short survey that will seek input from ophthalmologists regarding their experiences with LASA eye medications. See article below titled: “Survey Seeks Ophthalmology Input on Look-Alike, Sound-Alike Medication Errors”
    Washington Report Express

  1. March 8, 2012: ISMP Medication Safety Alert! Acute Care: Safety Brief: Product-related eye and ear medication errors. http://ismp.org/Newsletters/acutecare/issue.asp?dt=20120308 : The American Association of Eye and Ear Centers of Excellence (AAEECE) is conducting a “worldwide patient safety initiative” to review information about look and sound-alike medication names. As part of the initiative, AAEECE is conducting a brief survey on look- and sound-alike eye- and ear-related medication name mix-ups, which you can access at: www.surveymonkey.com/s/7FVF5T7.

  2. March 1, 2012: AAEECE WPSI Survey: Medication Errors/Incidents Involving LASA Eye and Ear Medications launched worldwide to collect data on LASA eye and ear medication errors.

“The AAEECE Worldwide Patient Safety Initiative (WPSI) to Address Look-Alike Sound-Alike (LASA) Eye and Ear Related Medication Errors by completing our new short survey that will allow us to collect data on LASA medication errors directly from our supporting members which include healthcare professionals (physicians, nurses, pharmacists, technicians, etc.) and patients. Just click on the following link which will bring you directly to our survey titled “AAEECE WPSI Survey: Medication Errors/Incidents Involving LASA Eye and Ear Medications” located on Surveymonkey: http://www.surveymonkey.com/s/7FVF5T7 . This 8 question multiple choice survey may take approximately 3 minutes or less. Please be specific when answering the 2 free text questions that pertain to the name(s) of the product(s) and the description and outcomes of the medication error/incident itself.

It is our intention to share this anonymous data with our supporting organizations, physician organizations, pharmaceutical manufacturers of ophthalmic and otic products, and the United States Food and Drug Administration (FDA) to highlight the affects of these LASA errors in different healthcare settings and in patient homes. You may learn more about the Worldwide Patient Safety Initiative and what has been accomplished thus far with your assistance by clicking on the following link *E-Petition News Link*: http://www.nyee.edu/lasa-e-petition-updates.html . We thank you for your time, your valuable feedback, and your ongoing support in addressing LASA eye and ear medication errors that affect our patients and healthcare colleagues alike worldwide. 

Please feel free to send the survey description above to your membership via e-mails and newsletters so we can collect a large sample of responses from colleagues and supporters throughout the world.

Thank you again.”

  1. February 18, 2012: The European Association of Hospital Pharmacists (EAHP), www.eahp.eu supports the AAEECE Worldwide Patient Safety Initiative to Address LASA Eye and Ear Medication ErrorsCelebrating their 40th year, the EAHP is a working community of national associations of hospital pharmacists. Its membership includes representatives of national hospital pharmacy associations in almost all the European Union (EU) member states, in addition to Switzerland, Norway, Serbia, Turkey, Croatia, the Former Yugoslav Republic Of Macedonia (FYROM) and Bosnia Herzegovina . Membership is increasing each year and, at present, EAHP represents the interest of over 21,000 hospital pharmacists in 31 countries all over Europe. We thank them for their support.”

  2. January 6, 2012:  Representatives of the Worldwide Patient Safety Initiative met with members of the American Academy of Ophthalmology (AAO)and the American Glaucoma Society (AGS) in Washington D.C. The delegation discussed the goals and accomplishments of the Initiative, the Patient Safety and Awareness Programs that have been created,  and how the organizations can effectively partner together with the AAEECE and the other national and international healthcare organizations supporting the Initiative to Address LASA Eye and Ear Medication Errors.

  3. December 2011: FREE Patient Education Pamphlets Titled: Safety Tips to Prevent Look-Alike Sound-Alike (LASA) Eye and Ear Drug Errors are now available in English, Spanish, and Chinese, and Russian. Just click on the link http://www.nyee.edu/lasa-e-petition-tips.html and select the language of your choice, and then print.

  4. April 2011: The New York Eye and Ear Infirmary Pharmacy Department creates a patient safety brochure titled “Safety Tips to Prevent Look-Alike Sound A-like (LASA) Eye and Ear Medications  for their hospital, clinic, and pharmacy patients (pictures provided by Bascom Palmer Eye Institute). This informative brochure identifies some commonly seen LASA Eye and Ear Drug pair names, provides some examples of LASA photos, and provides a Top 10 List: of Safety Tips to Prevent LASA Eye and Ear Drug Errors.  This list also provides sound advice for patients on the proper use of medications and a reminder to speak with your physician or your pharmacist if you have any medication related questions. You may view the contents of this brochure at: http://www.nyee.edu/highlights-2011i-NYEE-urges-awareness-of-lasa-drugs.html. You may also pick up a copy of this brochure while visiting New York Eye and Ear Infirmary.

  5. April 2011: The New York Eye and Ear Infirmary Pharmacy Department modifies their patient safety brochure titled “Safety Tips to Prevent Look-Alike Sound A-like (LASA) Eye and Ear Medications” so as to make it available to all  member hospitals of the American Association of Eye and Ear Centers of Excellence (AAEECE). This patient safety brochure will be distributed to patients at AAEECE member hospitals worldwide so that patient awareness to potential LASA Eye and Ear medication errors may increase. The brochure will also be sent out to all AAEECE Worldwide Patient Safety Initiative supporting healthcare organizations for distribution to their facilities, members, and patients.

  6. March 2011: The New York Eye and Ear Infirmary conducts a Patient Safety Awareness Fair in honor of Patient Safety Awareness Week (March 6-12, 2011). The Department of Pharmacy Services presents an educational booth titled “How to Prevent LASA Eye and Ear Medication Errors”. Photos of LASA drugs and name pairs were presented to the hospital staff and public. Many visitors shared personal and family experiences with these types of errors and offered their support to the Worldwide Patient Safety Initiative to Address LASA Eye and Ear Medication Errors.   

  7. September 2010: AORN: Calling all Health Care Professionals
    Please join AORN in our support of the AEECE Worldwide Patient Safety Initiative to Address Eye and Ear Look-Alike Sound-Alike (LASA) effort.  Complete this 3-minute survey to help AEECE raise public awareness of LASA medication errors as they collect valuable feedback from healthcare providers, patients, and supporters worldwide to enable systematic evaluation of which proposed improvements have the potential for application and benefit. For more information on the American Association of Eye and Ear Centers of Excellence, visit the AEECE web site.

  8. August 2010: The National Community Pharmacists Association (NCPA) sends out an e-blast to their membership asking them to complete the AAEECE Proposed Solutions Survey To Address LASA Eye and Ear Related Medication Errors.

  9. June 14, 2010: NCPA sends out an electronic newsletter to their membership which includes an article titled “Important Medication Safety Survey: Pharmacist Input Neededrequesting all NCPA Pharmacists to assist the AAEECE in collecting frontline pharmacist feedback on the Proposed Solutions for Eye and Ear Medications Rating Survey.

  10. June 14, 2010: The New York State Nursing Association (NYSNA) is asking its members to support the AAEECE Worldwide Patient Safety initiative by completing the AAEECE Proposed Solutions Surveys for Healthcare Professionals and Patients. The New York State Nurses Association is the nation's oldest and largest state professional association for registered nurses. It also is New York's largest union solely dedicated to promoting the interests of RNs and their patients. With more than 36,000 members, NYSNA has been the voice for nurses in New York state for more than a century. The association is affiliated on the national level with the American Nurses Association.

  11. May 24, 2010:  The Association of periOperative Registered Nurses (AORN) supports the AAEECE Worldwide Patient Safety Initiative. The Association of periOperative Registered Nurses (AORN) is the national association committed to improving patient safety in the surgical setting. AORN is the premier resource for perioperative nurses, advancing the profession and the professional with valuable guidance as well as networking and resource-sharing opportunities. AORN promotes safe patient care and is recognized as an authority for safe operating room practices and a definitive source for information and guiding principles that support day-to-day perioperative nursing practice.  AORN  collaborates with professional and regulatory organizations, industry leaders, and other healthcare partners who support their mission. AORN is comprised of approximately 32,000 members.  You can learn more about AORN at www.aorn.org.

  12. May 13, 2010: The National Community Pharmacists Association (NCPA) sends letter of support for the AAEECE Worldwide Patient Safety Initiative. “Thank you for your consideration of the National Community Pharmacists Association as a supporting organization.  I have discussed the AAEECE Worldwide Patient Safety Initiative with the NCPA Executive Committee, and you have our full support in your efforts to address the critical issue of eye and ear medication-related look alike sound alike errors that affect community pharmacists and the patients they serve.”The National Community Pharmacists Association (NCPA®) represents America’s community pharmacists, including the owners of more than 22,700 independent community pharmacies, pharmacy franchises, and chains. Together they represent an $88 billion health-care marketplace, employ over 65,000 pharmacists, and dispense over 40% of all retail prescriptions.

  13. May 10, 2010: AAEECE Pharmacy Working Group begins Patient Advocacy/Support Organizations Campaign for Patients with Visual Impairment to assist the AAEECE in collecting patient and healthcare practitioner feedback regarding LASA medication errors with eye and ear medications.

  14. May 7, 2010: The World Association of Eye Hospitals posts “WAEH supports AAEECE Initiative” on their website and includes links for healthcare workers and patients to sign the new online AAEECE Proposed Solutions For Eye and Ear Medications Surveys:

  15. May 1, 2010:  We Are Asking for Your Assistance
    We are presently asking all professional and patient advocacy/support organizations for members/patients with visual impairment to assist us in this common goal of eliminating the potential for patient and healthcare practitioner related medication errors that may occur as a result of the use of LASA eye and ear medications. We have collected many suggestions on methods of improving existing labeling systems used on eye and ear products and created a Proposed Solutions for Eye and Ear Medication Worksheet for Healthcare Professionals and Patients. Our online survey will enable you and your members to just click on the site, take approximately 3 minute survey, and then click on the done button. This survey can be taken by a patient or with the assistance of family member or caregiver.  We would greatly appreciate it if your send out the two links to all of your members, affiliates, and patients for frontline healthcare professional and patient feedback that we will be collecting and reviewing. If you choose you may printout the survey and send the completed surveys back to the address below for us to manually enter the data. Our goal is not to support the solution that is the most popular but instead to continue to raise public awareness, to share feedback and to collect more data from our supporters and patients worldwide, and then to systematically evaluate which proposed improvements have the potential for application and benefit. The two new survey websites are:

    AAEECE Patient Safety Initiative to Address LASA Medication Errors: Proposed Solutions for Eye and Ear Medications Rating Worksheet
    *For Healthcare Professionals:  www.surveymonkey.com/s/aaeecelasasurvey
    **For Patients:   www.surveymonkey.com/s/aaeecelasapatientsurvey**

  16. April 27, 2010: The World Association of Eye Hospitals (WAEH) sends a letter of support for the AAEECE Worldwide Patient Safety Initiative.  The WAEH is a worldwide network of eye hospitals. All WAEH hospitals are “centers of excellence” in the area of ophthalmology and focus on delivering the best and most safe ophthalmic care.  The following eye hospitals are members of the WAEH:

    The following members are associate members of the WAEH

    • Himalayan Eye Center - Nepal: associate member
    • Mechi Eye Center - Nepal: associate member
  17. April 23, 2010: The AAEECE receives a letter from the Division of Executive Operations Office of Executive Programs, Center for Drug Evaluation and Research Food and Drug Administration stating that the "FDA shares your concerns regarding medication errors. FDA agrees that accurate identification of medications is critical to preventing medication errors and potential harm to the public." Click on the link to read the letter.

  18. April 23, 2010: The American Society of Health-System Pharmacists is pleased to support the initiative by The American Association of Eye and Ear Centers of Excellence to eliminate look-alike, sound-alike medication errors with ophthalmic and otic products. ASHP is a 35,000-member national professional association that represents pharmacists who practice in hospitals, health maintenance organizations, long-term care facilities, home care, and other components of health care systems. ASHP is the only national organization of hospital and health-system pharmacists and has a long history of improving medication use and enhancing patient safety.

  19. April 1, 2010: In response to proposed solutions received from physicians, nurses, pharmacists and patients alike to improve present LASA labeling issues with eye and ear medications, the AAEECE has sent out the following AAEECE Worldwide Patient Safety Initiative to Address Eye and Ear LASA Medication Solutions Rating Worksheet to our supporting healthcare and patient organizations. The Pharmacy Working Group of the AAEECE, intends to collect a large sample of feedback from frontline practitioners and patients worldwide to see which proposed solutions would be most valuable in improving patient safety and in reducing medication errors. If you are interested in completing one of these worksheets click on the link above and follow the instructions.

  20. March 22, 2010: Continuum Health Partners in New York City prints a brief article in  their Connections Newsletter of March 22-28, 2010 titled “NYEE Pharmacy Leads Patient Safety Initiative”. New York Eye and Ear Infirmary is a member of Continuum Health Partners which represents a system of 5 metropolitan healthcare institutions in the New York City area.

  21. March 5, 2010: ABC World News Tonight with Diane Sawyer airs a segment on “Prescription Mix-Ups” that discussed medication errors and hazards due to LASA Drugs, Abbreviations, Standard packaging, etc. Although eye and ear medications were not reviewed specifically the segment highlights the relevancy of our Initiative in Pharmacy Practice and the potential for serious medication errors when using LASA medications in the community setting as well. Their link “See how drugs get mixed up at Pharmacies: Look-Alike Drugs Lead to Prescription Errors” also presents many pictures of other LASA Meds.
  22. March 1, 2010: The American Pharmacists Association (APhA) writes about our Initiative in an article by Beth Farnstrom titled AAEECE solicits support for initiative to eliminate look-alike sound-alike medication errors  that appears on the APha Newsroom page. This article also provides a link to our website and to other links associated with the Initiative.
  23. February 2010:   The Pharmaceutical  & Packaging News.com (PMP.COM) wrote an article titled “Package Color Coding Called into Question” which reviews our initiative from their perspective.
  24. February 26, 2010: The American Society of Ophthalmic Registered Nurses (ASORN) sends an e-blast notice to all of their members and affiliates to inform them of the AAEECE Patient Safety Initiative.
  25. February 24, 2010: National and international support/interest from healthcare professionals and lay people alike continues to grow on our E-Petition website. As of Feb 23, 2010 we have had over 107,952 visitors on our site. The 100k ceiling was broken in approximately 6 weeks!
  26. February 23, 2010: The Pennsylvania State Nursing Association (PSNA) places the AAEECE Patient Safety Initiative on their website titled  “e-Petition Related to Look-Alike Sound-Alike Ophthalmic Medication Errors
  27. February 10, 2010: The Pennsylvania State Nurses Association (PSNA) supports effort to address Eye and Ear LASA Medication Errors. The Association represents over 205,000 Registered Nurses in Pennsylvania.
  28. February 9, 2010: The American Pharmacists Association (APhA)  supports  the AAEECE Worldwide Patient Safety Initiative.
  29. February 5, 2010: Public interest and response great as approximately 70,000 hits recorded on website within 5 weeks of launch of  AAEECE Worldwide Patient Safety Initiative to Address LASA Eye and Ear Related Medication Errors. Feedback from healthcare professionals received throughout the world including the United States, Europe, Saudi Arabia, the United Arab Emirates, Australia, and New Zealand.
  30. February 5, 2010 the American Society of Ophthalmic Registered Nurses (ASORN) offers support and assistance with our Initiative.
  31. January 19, 2010: The Wall Street Journal print story titled "Catching Deadly Drug Mistakes" by Laura Landro on pages D1-D2 that includes brief discussion of eye drop related LASA errors. It includes our website as well as our picture of 3 eye drops that look alike on the front page.
  32. January 13, 2010: The Institute for Safe Medication Practices (ISMP) pledges support of the AEECE Worldwide Patient Safety Initiative to address LASA Eye and Ear Related Medication Errors.
  33. January 11, 2010: The AAEECE sends letter to the Commissioner of the FDA to Address Eye and Ear Related LASA Medication Errors.

SIGN THE E-PETITION HERE!

About The American Association of Eye and Ear Centers of Excellence (AAEECE)

formerly The American Association of Eye and Ear Hospitals (AAEEH)

The AAEECE is comprised of the world's premier centers for specialized eye and ear procedures.  Eye and ear specialty hospitals have led the way as providers of high-quality, cost-effective outpatient health care services.  The mission of these specialty institutions requires that they maintain leading edge technologies, enabling them to provide highly specialized services not available in general hospitals.  AAEECE member facilities serve as models of cost efficiency and high-quality care when surgery and services are rendered by specialty hospitals on an outpatient basis.  Association members are major nation-wide referral centers with a commitment to teaching, research and hands-on patient care of the highest level of quality.  These specialty hospitals routinely treat the most severely ill eye and ear patients.

The AAEECE is comprised of the following hospitals:

  • New York Eye and Ear Infirmary of Mount Sinai: New York, New York *E-petition Administrator
  • Bascom Palmer Eye Institute: Miami, Florida
  • Callahan Eye Foundation Hospital: Birmingham, Alabama
  • Manhattan Eye, Ear and Throat Hospital: New York, New York
  • Massachusettes Eye and Ear Infirmary: Boston, Massachusettes
  • Moorfields Eye Hospital United Kingdom: London, England
  • Phillips Eye Insitute: Minneapolis, Minnesota
  • Rotterdam Eye Hospital: Rotterdam, The Netherlands
  • Royal Victorian Eye and Ear Hospital: East Melbourne, Australia
  • Rutnin Eye Hospital: Bangkok, Thailand
  • St. Erik’s Eye Hospital: Stockholm, Sweden
  • Wills Eye Hospital: Philadelphia, Pennsylvania
  • Wilmer Eye Institute at John Hopkins: Baltimore, Maryland

For contact information please visit: http://www.aaeeh.org/locations.html

Department of Pharmacy Services

New York Eye and Ear Infirmary of Mount Sinai
310 East 14th Street
New York, NY 10003 (in Manhattan)
Tel: (212) 979-4378
Fax: (212) 353-5915
Email: lasaepetition@nyee.edu

This website is maintained by The New York Eye and Ear Infirmary of Mount Sinai.

TOP

 

Home > Departments > Pharmacy > E-Petition to Eliminate Look Alike Sound Alike Medication Errors > E-PETITION UPDATES