SALA Drug & Dangerous Medication Abbreviation - Resources

Utah Patient Safety Steering Committee - Adverse Drug Events User Group

Abbreviations and Sound Alike Look Alike Drugs (SALAD)

November 2008

Confusing product names, abbreviations, and dose expression are common causes of medication errors according to a review of a national medication error database. With over ten thousand brand and generic medication names currently on the market and more approved each year, it is easy to see the potential for error. Abbreviations of drug names or dosages exacerbate the problem.

Recommendations to Prevent Medication Errors

• Avoid abbreviations, especially QD, QOD, MS, MgS04, MS04, U, or IU as these have lead to more significant errors. All abbreviations should be discouraged through education (physician, nurse, pharmacist and RT) and review of pre-printed orders and electronic systems. See www.ismp.org/Tools/errorproneabbreviations.pdf
• No trailing zeros (1 not 1.0)
• Use leading zeros with decimals (0.1 not .1)
• Reduction of illegible handwriting through the use of electronic systems (CPOE, etc.) and pre-printed orders
• Use of bar-coding technology in
• Ordering
• Receiving
• Restocking
• Dispensing
• Administration
• Use of TALL man lettering which involves highlighting the differences in similar names (eg. EPINEPHrine and ePHEDrine or DOBUTamine and DOPamine) see www.ismp.org/tools/tallmanletters.pdf
• Physically segregate SALAD products
• Consider use of “name alert” stickers on selected SALADs storage areas
• Include the medication indication on orders
• Include generic and brand name on labels and computer systems
• When considering a new medication, dosage form, or concentration for use, physically review the product and consider the potential for look alike sound alike errors.
• Consider double checks for selected high alert SALAD medications
• If a verbal or telephone orders can not be avoided then use a READ back procedure such as hear, write, read, and confirm.

Resources

Intermountain Sample Documents HCA/MountainStar Sample Documents University Health Care Sample Documents Joint Commission's National Safety Patient Goal - SALA Drugs ISMP Medication Safety Alert - Tall Man Lettering