In the late 1950's, an infant girl with a high fever was taken to a newly licensed pediatrician who prescribed the wrong amount of the antibiotic erythromycin. The infant overdosed after receiving individual doses equal to an entire day's recommended amount. The child developed a severe hearing loss that may have marked her destiny to become an internationally recognized medication safety expert.

As Assistant Director of Pharmacy at Kings County Hospital, Dr. Miriam Klein, B.S., Pharm.D., is the leader behind a unique labeling and storage design system that prevents confusion over look-alike and sound-alike drugs and other high alert medications. The new labeling system at Kings County recently received kudos from the Joint Commission as a best practice in medication storage.

"I had always dreamed of becoming a pharmacist," says Dr. Klein, "My lifelong disability fuels my passion for helping others avoid such errors."

Mix-ups over drugs that have similar brand names, generic names, abbreviations and packaging are a common source of medication errors in healthcare facilities across the country. Anticoagulants, narcotics, insulin and sedatives are among some of the commonly used drugs considered high alert medications.

Dr. Klein first tackled the insulin bins affixed with old labels and stored with different types of insulin vials in the same container. The bins were replaced with new clear containers and easy to read, color-coded labels that match the color on the vial. In the front of the bin, bold red letters warn “High Alert” along with the name of the specific insulin drug, amount of units, and number of units in the vial.

Other look-alike and sound-alike drugs are identified with “Tall Man” letters on the labels. For example, PENTobarbital and PHENobarbital - different drugs that treat seizures - are partially spelled in upper case to draw attention to the differences in otherwise similar names. A yellow and red label on the back warns “Caution,” “Look-Alike” or “Sound-Alike” to further reinforce the potential risk.

“Similarly named medications can have very different therapeutic uses. We have built layers of checks and balances with a simple, inexpensive solution to ensure patients do not receive incorrect medications due to name confusion, or due to similar drug packaging, which can sometimes cause serious adverse drug events,” says Dr. Klein.

There are 1.5 million preventable adverse drug events in the US each year at an annual cost up to $5.6 million per hospital and a total cost to the US of $5.6 billion annually.

The new labeling system at Kings County Hospital is just one of a number of innovative medication safety programs, including bar-coded wrist bands that are scanned to ID and match the patient to the medication, and an automated medication reconciliation system that helps prevent negative interaction among drugs.

“Miriam has carved out a niche for herself that not many pharmacists have: a complete focus on medication safety. Her contagious passion has encouraged and energized staff to be vigilant. It helps make everyone an active participant in our patient safety success,” says Christopher Russo, R.Ph., Kings County Hospital Director of Pharmacy.

November 2009