There has to be a more systemic fix than just asking staff to be careful… staff are always supposed to double check meds anyway…
Hospital Tells Staff to “Be Careful” About These Meds
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Mark Graban
Author, Speaker, Consultant, Podcaster, Entepreneur - "The Mistakes That Make Us"
Given the number of drugs, strengths, formulations, made by different manufacturers on the market, it is completely unfeasible to have unique combinations of packaging and labels… I'd argue that were this to be attempted it would cause more problems, as people would use the colors, etc. as shortcuts…. thereby increasing the risk of errors (especially when you buy a different manufacturer's product e.g. during a backorder. It might well be preferable to have every label exactly the same color, etc., so that one is forced to read the label….
Eric – thanks for your comment. This is often a light-hearted blog, but this is a deadly serious issue.
Wake up pharmaceutical companies, indeed! We shouldn't be putting patients in that position and it's certainly not fair to healthcare professionals who might end up fired or in jail for giving the wrong medication (being part of a very systemic error).
As the general theme of this blog says, hanging signs and warnings and be carefuls is not enough. Not even close.
See this post on my main blog for an example of a change to packaging that was made a few years back – heparin vs. hep-lock:
https://www.leanblog.org/2010/04/quaid-patient-safety-documentary-airs-saturday-morning/
I have often thought of health care facilities as consumers of the pharmaceutical manufacturing companies. Health care consumers (you and I) are also consumers of the pharmaceutical manufacturers. Why is then, that we cannot force them to quit setting us up for potential disasters or failures. If a medication is labeled or packaged where it looks identical or very similar why can we, as consumers, not force the pharma industry to comply?
Ask nicely first, then use media campaigns to say who is not complying with the concern raised over SALAD (sound alike, look alike drugs). Social media is a great forum for it and very inexpensive. It sounds mean and possibly drastic, but I am very tired of looking at a vial 3-4 times to make sure I am administering the correct drug. As a leader, I am terrified I am putting my employees in jeopardy when ever they have to use a SALAD medication. We keep on putting more and more administrative burdens on already overworked or overloaded clinicians. The pharmaceutical industry should spend the few more pennies it would take to be inventive in their labeling or packaging so there are no more SALADs.