USP Quality Review

No. 78, Issued February 2004

Too Much Similarity

Conclusion/Recommendations

While facilities may not have direct control over the design and appearance of packaging and labeling and the physical product itself, healthcare professionals can take action to avoid these and similar errors from occurring. Identifying and applying cautionary labels to similar-looking products can aid in bringing to the staff's attention that the product they are about to dispense or administer should be handled with care. This measure encourages practitioners to take a second look at the product before they follow through with dispensing or administering the product.

Sometimes staff are not aware that a potential problem exists or that an error has occurred. Ensure that all staff are notified of potential problems by posting fliers, circulating newsletters such as this USP Quality Review that identify which products may cause confusion, sending e-mails, posting the information on your Intranet, or conducting an in-service education program. It is very important to find ways to reach every person in your institution. Remember to include floating and temporary staff, the night shift, and part-time employees.

Rewarding and recognizing staff is one of the most positive reinforcements facilities can use to engage staff and gather valuable information about medication errors. Encourage staff members to be proactive in identifying potential hazards. Provide incentives for identifying, reporting, and solving challenges for products that look similar.

Reporting to national programs such as the MER Program is an important measure in ensuring that information is shared with the U.S. Food and Drug Administration, the Institute for Safe Medication Practices, and manufacturers and labelers. In addition, information reported to the MER Program is disseminated back to healthcare professionals through USP Quality Reviews, Practitioners' Reporting (PR) News, and CAPSLink™. PR News items and CAPSLink can be viewed by visiting www.usp.org/practitionerPrograms/newsletters/.