Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions

Ryan, Alexandra N.;Robertson, Kelvin L.;Glass, Beverley D.

Abstract

Background: Look-alike medications, where ampoules or vials of intravenous medications look similar, may increase the risk of medication errors in the perioperative setting. Aim: This scoping review aimed to identify and explore the issues related to look-alike medication incidents in the perioperative setting and the reported risk reduction interventions. Method: Eight databases were searched including: CINAHL Complete, Embase, OVID Emcare, Pubmed, Scopus, Informit, Cochrane and Prospero and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR). Key search terms included anaesthesia, adverse drug event, drug error or medication error, look alike sound alike, operating theatres and pharmacy. Title and abstracts were screened independently and findings were extracted using validated tools in collaboration and consensus with co-authors. Results: A total of 2567 records were identified to 4th July 2022; however only 18 publications met the inclusion criteria. Publication types consisted of case reports, letters to the editor, multimodal quality improvement activities or survey/audits, a controlled simulation study and one randomised clinical trial. Risk reduction intervention themes identified included regulation, procurement, standardisation of storage, labelling, environmental factors, teamwork factors and the safe administration. Conclusion: This review highlighted challenges with look-alike medications in the perioperative setting and identified interventions for risk reduction. Key interventions did not involve technology-based solutions and further research is required to assess their effectiveness in preventing patient harm.

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International Journal of Clinical Pharmacy

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2210-7711

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Springer

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DOI

10.1007/s11096-023-01629-2