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5PSQ-137 Medication errors relating to isoappearances in the emergency room
  1. B Fernández García,
  2. C Fontela Bulnes,
  3. M Ercilla Liceaga,
  4. A Eceiza Díez,
  5. I Beristain Aramendi,
  6. A Ros Olaso,
  7. J Boo Rodriguez,
  8. T Gonzalez Fernández,
  9. B Odriozola Cincunegui,
  10. L Mendarte Barrenechea,
  11. MP Bachiller Cacho
  1. Hospital Universitario Donostia, Pharmacy Department, San Sebastián, Spain


Background and importance Medication errors (ME) are a common cause of harm to patients, especially in an emergency setting. The International Organization for Standardization (ISO) includes among the main objectives safety in the administration of medicines, sharing best practices and minimising the possibility of ME due to confusion of denominations and the external appearance of the products. This has the potential to significantly improve patient safety and the quality of healthcare. The World Health Organization (WHO) estimates that the annual cost of medication errors amounts to $42 billion, all potentially avoidable.

Aim and objectives The aim of this study was to determine the prevalence of ME related to isoapperances in the emergency room (ER), and to give visibility and enhance the importance of the recently created Isoappearance Group in the Emergency Department to achive ISO’s objectives.

Material and methods A retrospective observational study was performed. ME that occurred in the ER in our hospital during the years 2019, 2020 and the first half of 2021 were analysed through our hospital’s corporative electronic platform SNAPS (Patient Safety Notification and Learning System), developed by the Spanish Ministry, and available to all hospital professionals. In addition, the bibliography at the Institute for Safe Medication Practices (ISMP) website about ‘sound-alike’ and ‘look-alike’ errors was reviewed.

Results In the study period, 237 incidents were reported in the ER, and 44 of them were related to medication (18.5%). Specifically 22 of them (9.2%) corresponded to isoappearances (7 ‘sound-alike’ and 15 ‘look-alike’). Six (27%) of the registered isoappearances reached the patient and could have been avoided. Although they could have harmed the patients, all the incidents were resolved.

Conclusion and relevance ‘Sound-alike’ and ‘look-alike’ errors have a high frequency, and it is a priority to work specifically on them. To work on this objective, a multidisciplinary isoappearances group formed by a clinical pharmacist, a nurse, and two physicians has been set up on site in the ER to optimise stocks by reducing the available concentrations, changing the providers so that the medications’ appearance was different, and promoting safety culture.

Conflict of interest No conflict of interest

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