The Use of Graphic Design to Support Nurses in the Selection of Look-Alike Medications

Singh, Mina D.

Monday, 31 October 2011

Mina D. Singh, PhD, RN
School of Nursing, York University, Toronto, ON, Canada
Sandra Gabriele, MDes
Department of Design, York University, Faculty of Fine Arts, Toronto, ON, Canada
Sylvia Hyland, RPh, BScPhm, MHSc, (Bioethics)
Institute for Safe Medication Practices Canada, Toronto, ON, Canada
Laura Lin Gosbee, MASc
Red Forest Consulting, LLC, Ann Arbor, MI
Ross Evans, RPh, BScPhm, MA, (Journalism)
Child and Parent Resource Institute (CPRI), London, ON, Canada
Ajit Ninan, MD, FRCPC
Child and Adolescent Psychiatry, Schulich School of Medicine and Dentistry, London, ON, Canada
Olavo Fernandes, RPh, BscPhm, ACPR, PharmD, FCSHP
Clinical Director of Pharmacy, University Health Network, Toronto, ON, Canada
Judith Hart, RN, PhD
University Health Network, Toronto, ON, Canada

Learning Objective 1: graphically see how medication errors are made when the medication names look-alike/sound-alike

Learning Objective 2: be more cognizant in the administration of such medications

Worldwide, look-alike/sound-alike (phonetic and/or orthographic similarity) medication names have been identified as a cause of medication errors in nursing practice. The Federal Drug Administration and Institute for Safe Medication Practices recommend the use of tallman letters to selected parts of the names to help differentiate them from one another. There are few studies demonstrating the effectiveness of this strategy and fewer still that include nurses in the participant pool. This descriptive, exploratory study evaluated tallman lettering and alternative methods of differentiating look-alike medication names. This study used convenience sampling of nurses and pharmacists with varying levels of experience to participate in a series of experiments to measure accuracy and speed in the administration of medications that have look-alike names. The process of developing relevant tasks for the evaluation of the designs and findings will be presented.

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