March 24, 2006

Not all SALADs are good for you

A growing problem in keeping patients safe from medication errors is the confusion of medications that have similar sounding or looking names. If one medication is mistaken for another with a similar name, it can result in serious injury or even death. According to the Agency for Healthcare Research and Quality, approximately 15 percent of all reported medication errors are a result of this confusion.

As part of the MGH's commitment to improve patient safety and standards of care, the Safe Administration Subcommittee (SAS), under the charge of Medication Education Safety Administration Committee (MESAC), has established a new process that will help MGHers to better identify, order, dispense and administer medications that have similar sounding or looking names.

To help MGH staff keep patients safe, the following safeguards have been established:

• An initial Sound-Alike, Look-Alike Drug (SALAD) list has been created, and a laminated reference copy will be available on all inpatient units. Examples include: Celexa and Celebrex; Flurdarabine and Floxuridine; and Zoloft and Zocor. This list is reviewed and revised at least annually based upon a variety of information and audit results of MGH-based medication error incident reports reviewed by the SAS.
• Another feature to distinguish these drugs is the use of "TALLman lettering," which has been incorporated into the Omnicell and Pharmacy systems. TALLman lettering presents portions of a name in all capital letters to visually distinguish it from other similarly named drugs. Example: oxyCONTIN and OXYcodone.
• "Shelf talkers" (shown below) are labels that will be used in non-automated areas to provide a visual warning to practitioners to double-check the medication before dispensing or administering.

The SALAD system and its oversight by the SAS broadens previous efforts to reduce the risk of errors at the MGH. These innovations will help the MGH better meet National Patient Safety Goal #3 to improve the safety of using medications and is a part of the hospital's enhanced readiness for the upcoming survey by the Joint Commission on Accreditation of Healthcare Organizations. Employees can find additional information about SALAD by visiting the MESAC website at http://intranet.massgeneral.org/MESAC/. The SALAD policy can be viewed in the online Clinical Policy and Procedure manual.

"The use of the SALAD policy throughout the MGH will make everyone involved in the medication use process more aware of potential errors that can occur anywhere," says Meg Clapp, director of MGH Pharmacy.