Journal Article

Addressing the risk of look-alike, sound-alike medication errors: bending metal or twisting arms?

Phipps, Denham L

2025

Overview

According to their framework, the challenge for such research is to reconcile theoretical grounding (which favours abstraction and methodological rigour in order to isolate the critical mechanisms at play in a given situation) with an orientation towards practical problems (which favours consideration of healthcare concerns and representation of the typical actors, tasks and environments in order to demonstrate applicability). Or, looking to a design solution, might Tallman lettering, which appears to have equivocal support as a solution to medication errors,5 be of most benefit when distinguishing between unfamiliar drug names, as previously suggested by DeHenau et al9? Another implication from Lambert et al’s findings is to consider minimising word length (and possibly also to avoid uncommon letter pairings) when devising drug names at the outset, which would add to the guidance currently available on name design.10 11 Incidentally, it would have been helpful to see the partial regression coefficients that the authors obtained from their analysis to tease out any direct but subtle effect of drug name composition and familiarity on real-world error rates (insofar as the error data collected for this study reflect the actual occurrence of errors; an assumption that, as the authors themselves acknowledge, comes with the caveats of a restricted sampling frame and the inherent limitations of self-reported error data). Community pharmacy, the immediate context for their study, is a key component of primary care medication supply but also a challenging setting in which to work, requiring the coordination of various system elements in order to meet multiple and interacting goals.12 13 As a result, there are other matters to consider with regard to LASA errors. Should a human-centred approach to product design and evaluation be adopted within the supply chain?

• Publisher: BMJ Publishing Group LTD
• Subject: Ergonomics / Medical errors / Names / Patient safety / Pharmacy / Product design / Silver / Suppliers