To Err Is Human - Part 2: The Role of Pseudo-Homophones in Medication Errors & Associated Prevention Strategies

Jubilant Radiopharma Radiopharmacies Division. presents the second installment of Dr. Laura Bauman’s To Err Is Human, a blog series focused on common errors in nuclear medicine that may occur during the process of writing, ordering and/or dispensing prescriptions. This series also emphasizes the critical importance for organizations to establish error prevention strategies.

In this installment, Dr. Bauman addresses how to guard against potential errors resulting from sound-alike numbers when verbally communicating prescription orders.   

We’re all familiar with homophones — words that are pronounced (and sound) the same but have different meanings. For example: they’re, there and their. While not homophones, number words ending in -ty and -teen are considered pseudo-homophones — words that, when pronounced, sound similar and could be easily confused. In our industry, pseudo-homophones create potential problems when prescription orders are called in or received via voice mail, especially when appropriate dosages span a large range and when the procedure for the drug is not specified. The number 40, for example, can easily be misinterpreted as the number 14.

Luckily, this common problem can be easily resolved by implementing a practice of repetition and clarification by both the pharmacy receiving the prescription order and the nuclear medicine department placing the prescription order. For example, communicators mindful of potential confusion when verbalizing number values can clarify the dose amount by re-stating individual numbers as follows: “forty, four-zero” or “fourteen, one-four.”  Another safeguard is to always specify the procedure along with the drug.  A 15 microcurie I-131 capsule and a 15 millicurie I-131 capsule error can potentially be prevented by knowing whether the capsule is for uptake or for therapy.  Spelling out “milli” or “micro” certainly helps as well.

While this solution may seem simplistic, adding that simple step to your routine when relaying numbers can pay big dividends. Needless to say, any error in communication can impact patient care, cost and efficiency. We may think that, with so few drugs in our niche field, we are immune to the widespread problems of medication errors, but there are always opportunities for improvement through education and implementation of best practices.

Did You Say 50 mCi or 15 mCi?

In one recent example of confusion caused by a pseudo-homophone number, the pharmacy dispensed a 50 mCi custom compounded I-131 capsule instead of the 15 mCi capsule the nuclear technologist believed he had ordered.

Fortunately, the technologist assayed the capsule before administering the higher dose to the patient. When the error was reported, another custom capsule was made and immediately sent so the patient could be treated on the same day.

Once the situation was rectified, the pharmacist and technologist discussed what had happened and how to avoid future misunderstandings. Moving forward, they agreed to read back all numbers that could be verbally confused before finalizing the order. Thus, the standard practice for ordering the correct dose now includes the following instruction: “I need a fifty millicurie I-131 capsule — that's five-zero — fifty millicuries for a therapy dose.”

As important as it was to resolve this individual problem, it was even more important to pass on the lessons learned. Thanks to active participation in a system of just culture, this case study was shared with all of the pharmacists at the location…and now with all of you. Through this method of information sharing, many people now are familiar with techniques designed to prevent similar errors from happening again.

 — Stay tuned for Dr. Bauman’s next Industry Insider Blog installment in the To Err Is Human series: “Brought to You by the Letter M” will address the use of abbreviations when communicating or writing down medications.

Jubilant Radiopharma Radiopharmacies Division's Online Prescription Ordering System can help your nuclear medicine department avoid many of the common communication mistakes that lead to dispensing errors. Now available through Jubilant Radiopharma Radiopharmacies Division's pharmacies nationwide, Online Prescription Ordering provides a quick, easy and secure way to transmit your prescription orders directly to your local pharmacy. Contact your Jubilant Radiopharma Radiopharmacies Division pharmacist to register today.