E-Petition to Eliminate Ophthalmic Look Alike Sound Alike Medication Errors |
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Sponsored by The American Association of Eye and Ear Centers of Excellence (AAEECE), formerly The American Association of Eye and Ear Hospitals (AAEEH) |
Sign the E-Petition Here!
Dear Healthcare Provider,
On behalf of The American Association of Eye and Ear Centers of Excellence (AAEECE), formerly The American Association of Eye and Ear Hospitals (AAEEH), and the patients we serve, I am writing to ask your assistance with an issue that continues to threaten patient safety in our facilities and for many ophthalmic patients. The issue relates to look-alike sound-alike (LASA) ophthalmic medication errors.
THE LASA ISSUE
In an operating room a nurse mistakenly selects a Cyclopentolate 1% 2mL ophthalmic solution instead of a Tropicamide ophthalmic solution 3mL from a standardized dilation tray. A pharmacist dispenses a 5mL Tobramycin and Dexamethasone ophthalmic suspension instead of a 5mL 1% Prednisolone Acetate ophthalmic suspension from his supply of ophthalmic medications. At a Veterans Administration Center eardrops were dispensed as eye drops following cataract surgery1. An elderly patient with glaucoma incorrectly self- administers his glaucoma eye drops instead of his anti-inflammatory eye drops because “the letters and bottles all look the same to me”. These are just some examples of ophthalmic medication related look-alike sound-alike (LASA) medication errors that occur on a daily basis here in the United States and worldwide in hospitals, pharmacies, physician offices, ambulatory clinics or in a patient’s home. Medication errors due to LASA drugs are common in the United States and are responsible for thousands of injuries, deaths, and millions of dollars in additional medical and legal costs to our healthcare system annually. Up to 25% of all medication errors are attributed to name confusion, while 33% have been attributed to packaging and or labeling confusion2. Dispensing or administering, ophthalmic solutions or suspensions are especially problematic when one considers existing manufacturer specific color-coding of bottles and the repetitive use of similar lettering and company symbols.
BACKGROUND
In 1996 the problem was unintentionally exacerbated when the Academy of Ophthalmology (AAO) endorsed a color-code scheme system of identifying eye drops by therapeutic class in an effort to minimize ophthalmologist drugs selection errors. This system was later approved by the FDA and manufacturers on a voluntary basis. Examples of this system include: anti-infectives ophthalmic containers and caps have tan caps and backgrounds, mydriatics and cycloplegics containers use a red cap and background, miotics use green, beta-blockers use yellow or blue, and so on. The Institute of Safe Medication Practices (ISMP) wrote “that despite the Academy’s intention to reduce errors, the downside of color coding products in this manner is that items within each class become more difficult to differentiate. Also when similar corporate logos, fonts, package sizes, and color combinations are factored in, what may work well in an office setting or in a patient’s home does not necessarily work well in pharmacies or on the nursing units4.” In 2005, despite the ISMP’s effort to convince the AAO, the FDA, and drug manufacturers to change their color coding system on the basis of improving medication and public safety, no changes were made to any ophthalmic bottles, labeling, colored caps, or containers.
NATIONAL EFFORT REQUIRED
In an effort to directly address these medication safety issues that affect our hospitals, physicians, nurses, pharmacists, and patients on a daily basis, The American Association of Eye and Ear Centers of Excellence (AAEECE), formerly The American Association of Eye and Ear Hospitals (AAEEH), are asking for the AAO and other domestic and international organizations to support and partner with us to review existing patient safety literature and medication error reports that pertain to these products and to promote new research to identify best systems and safety improvements that will benefit both patients and healthcare professionals with/without visual impairment. We urge manufacturers to work with us in revising existing policies and practices of packaging these drugs which include a review of color coding, color schemes, fonts, plastic wrapping designs and logo placement on external boxes as well as on the immediate drug container. We also ask that the pharmaceutical manufacturers adopt new and innovative safety practices when naming and manufacturing new ophthalmic solutions and containers (ex. Cosopt and Azopt). Finally, we urge that they also conduct risk assessments programs, prior to the marketing of new drugs, that include patients with visual impairment and "front line" healthcare professional for feedback which includes a review of the administration, dispensing, storing, and distribution of potential LASA medications.
We have included some photos of ophthalmic solutions and suspensions (clear and blurry to highlight how the bottle is viewed by someone with or without visual impairment) that are considered LASA drugs groupings that have resulted in patient medication errors due to their similarities.
**EXAMPLES OF LOOK-ALIKE OPHTHALMIC MEDICATIONS**
Normal Vision Viewpoint and Impaired Vision viewpoint |
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Click on the image to view a larger photo |
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View the AAEECE letter to FDA >>
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: 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
The New York Eye and Ear Infirmary
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.
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Main Number: 212-979-4000 • Physician Referral Line: 212-979-4472
