Are electronic prescribing systems increasing the risk of ‘look-alike sound-alike’ medication errors?
The tragic death of a three-week-old baby, Sidra Aliabase, in 2024, due to a prescribing error, highlights the ongoing risk of 'look-alike sound-alike' (LASA) medication errors in electronic prescribing systems. This incident, where sodium acid phosphate was prescribed instead of sodium chloride, underscores the potential dangers of these systems, especially when drugs have similar names. The coroner's report and the doctor's confirmation in court reveal a clear case of human error in the electronic prescribing process.
The issue of LASA errors is not new, but the shift to electronic prescribing systems has raised concerns. While electronic prescribing is intended to reduce medication errors by 30%, the examples provided in the article demonstrate that these systems can introduce new types of errors, particularly those related to LASA medicines. The challenge lies in the transition from traditional paper-based systems to electronic ones, where the risk of LASA errors may be transferred or even amplified.
The article explores the complexities of data collection and analysis regarding LASA errors. The dual reporting systems in place during the transition period (2021-2024) and the lack of a specific category for LASA incidents make it difficult to obtain accurate data. Bryony Dean Franklin, Professor of Medication Safety, suggests that LASA errors in traditional systems may have been replaced by new errors in electronic systems, as the handwriting-related errors have been mitigated by the drop-down menus.
Julia Scott, a pharmacist and chief information officer, emphasizes the need for a comprehensive approach to mitigate LASA errors. She proposes implementing 'tall-man lettering' and changing how drugs are grouped to distinguish similar-sounding medications. Scott also advocates for the integration of clinical decision support AI to provide real-time prompts and reduce errors. However, she warns about the potential risks associated with ambient voice technology (AVT) or 'AI scribes', which could introduce new LASA error mechanisms.
The article also introduces the 'Touchdose' system, a clinical decision support tool that matches doses to indications, reducing LASA errors. A study comparing electronic and paper-based prescribing found that while errors involving incorrect doses and illegible orders were less common with electronic systems, those involving duplication, omission, incorrect drug, and formulation were more prevalent. The under-reporting of LASA errors is another concern, as only a small percentage of errors are reported, making it challenging to assess the true scale of the problem.
In conclusion, the article highlights the ongoing challenges of LASA errors in electronic prescribing systems. While these systems have the potential to reduce medication errors, the transition process and the introduction of new technologies like AI and AVT may introduce new risks. The need for comprehensive error mitigation strategies, improved data collection, and a deeper understanding of cognitive mechanisms are essential to ensure patient safety in the digital age of prescribing.
