ErrorinSpokenMedicationOrders

ListenCarefully:TheRiskofErrorinSpokenMedicationOrders

BruceL.Lambert,Ph.D.1,2,LauraWalshDickey,Ph.D.3,WilliamM.Fisher,Ph.D.4,RobertD.Gibbons,
Ph.D.5,SwuJaneLin,Ph.D.1,PaulA.Luce,Ph.D.6,ConorT.McLennan,Ph.D.7,JohnW.Senders,Ph.D.8,
ClementT.Yu,Ph.D.9

DepartmentofPharmacyAdministration,UniversityofIllinoisatChicago;2DepartmentofPharmacy

Practice,UniversityofIllinoisatChicago;3DepartmentofCommunicationScienceandDisorders,
UniversityofPittsburgh;4WilliamM.FisherConsulting,Inc.,Gaithersburg,MD;5CenterforBiomedical
Statistics,DepartmentofPsychiatry,UniversityofIllinoisatChicago;6DepartmentofPsychology,
UniversityatBuffalo;7DepartmentofPsychology,ClevelandStateUniversity;8FacultyofApplied
Science,UniversityofToronto,Toronto,Ontario,Canada;9DepartmentofComputerScience,University
ofIllinoisatChicago.Afterthefirstauthor,theorderoftheremainingauthorsisalphabetical.

CorrespondingAuthor:BruceL.Lambert,Ph.D.
Address:

DepartmentofPharmacyAdministration,

833S.WoodStreet(M/C871),Chicago,IL606127231

Phone:

3129962411

Fax:

3129960868

Email:

lambertb@uic.edu

WordCount:

7991

ErrorinSpokenMedicationOrders

Abstract

Cliniciansandpatientsoftenconfusedrugnamesthatsoundalike(Hicks,Becker,&Cousins,

2008).Weconductedauditoryperceptionexperimentstoassesstheimpactofsimilarity,familiarity,
backgroundnoiseandotherfactorsoncliniciansandlaypersonsabilitytoidentifyspokendrugnames.
Accuracyincreasedsignificantlyasthesignaltonoise(S/N)ratioincreased,assubjectivefamiliaritywith
thenameincreasedandasthenationalprescribingfrequencyofthenameincreased.Forcliniciansonly,
similaritytootherdrugnamesreducedidentificationaccuracy,especiallywhentheneighboringnames
werefrequentlyprescribed.Whenonenamewassubstitutedforanother,thesubstitutednamewas
almostalwaysamorefrequentlyprescribeddrug.Objectivelymeasurablepropertiesofdrugnamescan
beusedtopredictconfusability.Themagnitudeofthenoiseandfamiliarityeffectssuggeststhatthey
maybeimportanttargetsforintervention.

SingleSentenceSummary:Theabilityofcliniciansandlaypeopletoidentifyspokendrugnamesis
influencedbysignaltonoiseratio,subjectivefamiliarity,prescribingfrequency,andthesimilarity
neighborhoodsofdrugnames.

ErrorinSpokenMedicationOrders

Introduction

Inclinicalmedicine,therisksofmisinterpretationoftelephoneordersarewidelyrecognized

(Koczmara,Jelincic,&Perri,2006;PennsylvaniaPatientSafetyAuthority,2006;TheJointCommission,
2008).Theuseofthetelephonetocommunicatemedicationordersleadstoerrorbecauseofboth
ambientnoiseandthelimitedbandwidthofmosttelephones(Aronson,2004;Hoffman&Proulx,2003;
Lambert,2008;Rodman,2003;Wiener,Liu,Nelson,&Hoffman,2004).Telephonestypicallycarrysignals
between300Hzand3kHz,amuchnarrowerbandwidththanthatofFMradio(30Hzto15kHz)orCD
audio(20Hzto20kHz);whereas,muchoftheimportantacousticinformationthatallowspeopleto
distinguishbetweensimilarconsonantsoundsliesabove3kHzandismissingentirelyfromthe
telephonesignal(Rodman,2003).Thereare3.8billionprescriptionsdispensedinoutpatientpharmacies
annuallyintheUnitedStates(IMSHealth,2008).Telephoneordersaccountfor34%ofretail
prescriptionvolume.Thistranslatesto114milliontelephoneprescriptionsannually,or312,000perday.
Onestudyof813telephoneorderstotwochainpharmaciesfoundthatthewrongmedicationnamewas
transcribedin1.4%oftheorders(Camp,Hailemeskel,&Rogers,2003).The1.4%ratemaynotbea
generalizableestimate,butgiventhenumberofopportunities,evenaverylowerrorratewould
translateintoalargenumberoferrors.

Spokenorderswereoncecommonininpatientsettingsalso,althoughlesssoafteraccrediting

agenciespressedfortheirelimination.One346bedhospitalcounted4197medicationrelatedverbal
ordersinasevendayperiod(Wakefield,etal.,2008).Hospitalpharmacistsreported35minutesofevery
8hourshiftwerespentresolvingproblemswithspokenorders(Allinson,Szeinbach,&Schneider,2005).
Respondentsidentifiedpeopletalkinginthebackgroundandbackgroundnoiseasthegreatest
barrierstothecorrectprocessingofspokenorders.Otherfactorsincludedlackoffamiliaritywiththe

ErrorinSpokenMedicationOrders

patientsclinicalconditionorthemedication,badconnectionsandexcessivelyrapidspeech(Allinson,et
al.,2005).

Theuseofcellphonesandvoicemailandthenoisyenvironmentsinwhichordersaresentand

received,increasetheriskofspokenprescriptionordersbeingmisperceived.Therearemanyexamples
ofauditoryperceptionerrors,somewithfatalconsequences(e.g.,Liquibidvs.Lithobid,Cardenevs.
codeine,Lopidvs.Slobid,erythromycinvs.azithromycin,Klonopinvs.clonidine,Viscerolvs.vistaril,
Orgaranvs.argatroban)(Allinson,etal.,2005;Dr.ordersLiquibidLithobiddispenseddeathresults.
Caseonpoint:Cliffordv.GeritomMed.,Inc.,681N.W.2d680MN(2004),"2004;Koczmara,etal.,2006;
PennsylvaniaPatientSafetyAuthority,2006;Vivian,2004).

Identifyingthefactorsthatinfluenceaccuracyintheperceptionofspokendrugnamesmay

facilitateinterventionsdesignedtomaketelephoneorderssafer.TheU.S.FoodandDrugAdministration
andthepharmaceuticalindustryhavestruggledtodevelopmethodsforevaluatingtheconfusabilityof
newdrugnames(U.S.FoodandDrugAdministration,2008).Wehaveshownthatobjectivemeasuresof
similarityandprescribingfrequencycanreliablypredicttheprobabilitythattwonameswillbeconfused
invisualperceptionandshorttermmemory(Lambert,1997;Lambert,Chang,&Gupta,2003;Lambert,
Chang,&Lin,2001b;Lambert,Donderi,&Senders,2002;Lambert,Lin,Gandhi,&Chang,1999;Lambert,
Yu,&Thirumalai,2004),andwehavedescribedprocessesfordesigningsaferdrugnames(Lambert,Lin,
&Tan,2005).Oneimportantpartofthatprocessistouseestablishedexperimentalparadigmsfrom
psycholinguisticstoevaluatetheconfusabilityofproposeddrugnamesinrelevanttasks(e.g.,auditory
perception,visualperception,andshorttermmemory).Anearlierstudyofnoiseandpharmacy
dispensingerrorsfound,counterintuitively,thatnoiseimprovedperformance,butrecommendedthat
morecontrolledexperimentsbedonetoclarifytherelationshipbetweennoiseanderrorrates(Flynn,
Barker,Gibson,&others,1996).Inthisstudy,wesoughttodemonstratehowthistypeof
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ErrorinSpokenMedicationOrders

experimentationcouldshedlightonthefactorsthatinfluenceauditoryperceptionofdrugnames.Thus
oneofthekeychallengesweaddressedwastotranslatethebasicscienceofauditorywordperception
intotheapplieddomainofdrugnameconfusion.Theworkwasdesignedtodeterminehowandtowhat
extentcharacteristicsofdrugnames,ofordertakers,andofpracticeenvironmentsaffectalisteners
abilitytoidentifyspokendrugnames.
AuditoryWordPerception

Toexplainauditoryperceptualconfusions,weuseLucesNeighborhoodActivationModel

(NAM)(Grossberg,1986;Luce,Goldinger,Auer,&Vitevitch,2000;Luce&Pisoni,1998;Vitevitch&Luce,
1999).Accordingtothismodel,stimulusinputactivatesasetofsimilarsoundingacousticphonetic
patternsinmemory.Theactivationlevelsoftheacousticphoneticpatternsareafunctionoftheir
degreeofmatchwiththeinput.Inturn,thesepatternsactivateasetofworddecisionunitstunedtothe
acousticphoneticpatterns.Theworddecisionunitscomputeprobabilitiesforeachpatternbasedonthe
intelligibilityandfrequencyofoccurrenceofthewordtowhichthepatterncorrespondsandthe
activationlevelsandfrequenciesofoccurrenceofallothersimilarsoundingwordsinthesystem.The
worddecisionunitthatcomputesthehighestprobabilitywins,anditswordiswhatisheard.Inshort,
worddecisionunitscomputeprobabilityvaluesbasedontheacousticphoneticsimilarityofthewordto
theinput,thefrequencyoftheword,andtheactivationlevelsandfrequenciesofallothersimilarwords
activatedinmemory.

TheNAMpredictsthatmultipleactivationhasconsequences:Spokenwordswithmanysimilar

sounding,higherfrequency(ormorecommonlyoccurring)neighborswillbeprocessedmoreslowlyand
lessaccuratelythanwordswithfewneighbors.Thesepredictionshavebeenconfirmedin

ErrorinSpokenMedicationOrders

manystudies:Wordsindenselypopulated,highfrequencysimilarityneighborhoodsareindeed
processedlessquicklyandlessaccuratelythanwordsinlowdensity,lowerfrequencyneighborhoods,
andwordswithhigherfrequencyofoccurrenceareprocessedmorerapidlyandaccuratelythanlower
frequencywords(Jusczyk&Luce,2002;Lambert,etal.,2003).

TheNAMemploysanexplicitmathematicalfunctionthatattemptstopredictauditory

perceptualerrorsbasedontheintelligibilityofstimulusword,thefrequencyofoccurrenceofthe
stimulusword,andthesimilarityandfrequencyofneighboringwords.Thisfunctionisknownas
frequencyweightedneighborhoodprobability(FWNP).Detailedmathematicaldescriptionsofthe
functionusedtocomputeFWNPforeachnamearegivenelsewhere(Jusczyk&Luce,2002;Lambert,Lin,
Toh,etal.,2005).Otherthingsbeingequal,FWNPwillincreaseasthenumber,similarity,and
prescribingfrequencyofneighborsdecrease.TheNAMprovidedtheframeworkforthedevelopmentof
severalhypothesesaboutauditoryperception:(1)AccuracywillincreaseasFWNPincreases.(2)
Accuracywillincreaseasthesignaltonoise(S/N)ratioincreases.(3)Accuracywillincreaseasobjective
prescribingfrequencyofthetargetnameincreasesand(4)Accuracywillincreaseassubjective
familiaritywiththetargetnameincreases.

Althoughfrequencyandneighborhoodeffectsarewellestablishedinthestudyofordinary

words,wesoughttoextendthisunderstandinginthreeways.First,weplannedtostudypropernames
fromlarge,closedsetlexicon(drugnames).Mostpreviousworkhasbeendoneinopensetconditions,
anditwasnotclearwhethertypicalneighborhoodeffectswouldbepresentinalarge,closedsetlexicon
condition(Clopper,Pisoni,&Tierney,2006;Sommers,Kirk,&Pisoni,1997).Second,wewishedtostudy
multisyllabicwordsratherthanthemonosyllabic(oftenconsonantvowelconsonant)wordsthathave
typicallybeenusedinstudiesofneighborhoodeffects.Thatrequiredustodevelopmeasuresof
similarityandnewmeasuresofFWNPformultisyllabicwords(Lambert,Lin,Toh,etal.,2005).Third,we
6

ErrorinSpokenMedicationOrders

wishedtoseewhethertheneighborhoodeffectswouldbepresentinbothexperts(clinicians)and
novices(laypeople).Weexpectedneighborhoodeffectsinexpertsbecause,presumably,theywould
possesslexicalrepresentationsoflargenumbersofdrugnames,andtheserepresentationswould
competeinthemannerdescribedabove.Wethoughtneighborhoodeffectsmightbeattenuatedor
absentinlaypeople,whomaylackrepresentationsformostdrugnamesandhencewouldnot
experiencethecompetitionthatcausesneighborhoodeffects.

Evenifwewerenotmakinganyoriginalcontributiontothebasicscienceofauditoryperception,

webelievethattheNAMprovidesapowerfulconceptualandexperimentalframeworkfor
understandingdrugnameconfusion,onewhichcouldadvanceworldwideeffortstopredictandprevent
sucherrors.Thusthepresentpaperisofferedasanexemplaroftranslationalresearch,whereconcepts
wellknowntoonecommunityareappliedtoproblemsinadifferentdomain(Woolf,2008).

Weattemptedtocontrolforalargesetoffactorsthatmightbeassociatedwithnameconfusion

errorrates.Amongthesewasthetypeofname(brandorgeneric).Onemightexpectbrandnamestobe
moreconfusingsincetheyaretypicallyshorter(Lambert,Chang,&Lin,2001a),andshorternamestend
tohavemoreneighbors(Andrews,1997;Luce&Pisoni,1998;Storker,2004).Conversely,genericnames
useacommonsystemofstems(i.e.,suffixes)whichtendstoincreasetheiraveragesimilaritytoone
another,therebyincreasingtheirconfusability(Lambert,etal.,2001a).Eitherway,thedistinction
betweenbrandandgenericnamesisanimportantoneinpractice,sowedesignedourexperimentsto
takeitintoaccount.

ErrorinSpokenMedicationOrders

MaterialsandMethods
Design

WeusedawithinparticipantsdesigntoexaminetheeffectofS/Nratio,prescribingfrequency,

subjectivefamiliarity,andsimilarityneighborhoodsontheabilitytocorrectlyidentifyspokendrug
names.AllparticipantsheardanequalnumberofdrugnamesatallthreeS/Nratiosandallofthedrug
namesappearedatallthreeS/Nratios.Threeversionsoftheexperimentensuredthatdrugnamesand
S/NratioswerecounterbalancedacrossparticipantsandthatparticipantsonlyheardoneS/Nratio
versionofeachdrug.
Participants

Participantswerepaidforparticipating.Theexperimentwasapprovedbytheinstitutional

reviewboardsattheUniversityofIllinoisatChicagoandatClevelandStateUniversity.Sixtyseven
pharmacistswererecruitedatthe2005meetingoftheAmericanPharmacistsAssociation,76family
physiciansatthe2005meetingoftheAmericanAssociationofFamilyPhysicians,and74nursesatthe
2005meetingoftheAcademyofMedicalSurgicalNurses.Duetoequipmentmalfunctionornonnative
languageaccents,5pharmacists,2physicians,and4nurseswereexcluded,leavingN=62pharmacists,
N=74physiciansandN=70nursesforthemainanalysis.Fortythreelaypeoplewererecruitedfromthe
communitysurroundingClevelandStateUniversity.1 Allclinicianswerelicensedandactivelypracticing
atthetimeofthedatacollection.NonnativespeakersofAmericanEnglish,lefthandedindividuals, 2

Infact60laypeoplewererecruited,butfundswereavailabletotranscribeonlythefirst43setsofresponsesfor
themainanalysis.

Itiscustomarytoexcludelefthandedparticipantsfromlanguageresearchbecauserighthanderstypically
representandprocesslanguageintheirlefthemisphere,andthereismorevariabilityinhowlefthanders
representandprocesslanguage.Hemisphericdifferencescouldhaveconsequencesforthespeedand/oraccuracy
withwhichlanguageisprocessed.So,toreduceunnecessarynoiseinthedata,lefthandersareoftenexcluded.
8

ErrorinSpokenMedicationOrders

andanyonewithseriousspeechorhearingproblemswereexcluded(Gonzalez&McLennan,2007;
Hagmann,etal.,2006).
StimulusMaterials

Weselected99brandand99genericdrugnames.Namesandprescribingfrequency

informationweredrawnfromfoursources:(1)theNationalAmbulatoryMedicalCareSurvey
(NAMCS),(NationalCenterforHealthStatistics,2001a).(2)theNationalHospitalAmbulatoryMedical
CareSurvey(HAMCS)(NationalCenterforHealthStatistics,2001b), (3)theIMSHealthNational
PrescriptionDrugAudit(NPDA)(IMS,2001),and(4)theSolucientHospitalDrugUtilizationDatabase
(SolucientInc.,2003).

Afrequencyweightedneighborhoodprobability(FWNP)wascomputedforeachname,

accordingtoaproceduredescribedelsewhere(Lambert,Lin,Toh,etal.,2005).Nameswerestratifiedby
FWNP,withtenbrandandtengenericnamesfromeachdecileofFWNP.Onebrandnameandone
genericnamewereremovedtomakethetotalevenlydivisibleintothreeS/Nconditions.Thenames
wereprofessionallyrecordedbyatrainedphonetician/phonologist.Thesereferencepronunciations
werebasedonphonemictranscriptionsfromexperiencedclinicians,collectedforadifferentproject.
EachrecordednamewaseditedintoanAIFFaudiofile.Tomimicthebandwidthlimitationsoftelephone
audio,frequenciesbelow300Hzandabove3kHzwerethendigitallyfiltered(Rodman,2003).

Stimulusdegradation.Drugnameswereplayedbackagainstabackgroundofstandard20

speakerbabble(obtainedfromAuditecofSt.Louis).Thenoisewasplayedatameanamplitudeof65dB
andwasnotbandwidthlimited(Flynn,etal.,1996).Thestimuliwereplayedateither63dB,68dB,or

ErrorinSpokenMedicationOrders

73dB,resultinginthreeS/Nconditionsof2dB,+3dB,and+8dBrespectively. 3 Asubgroupof10lay
participantscompletedtheexperimentintheclearwithnoaddednoise.
ExperimentalProcedure

Lettersweremailedtoattendeesinadvance,andindividualswereapproachedatthe

conventioncenterandasked:(a)iftheywerelicensed,practicingcliniciansintheU.S.and(b)ifthey
wereinterestedinparticipatinginastudyofdrugnameconfusion.Participantsconsented,completeda
demographicquestionnaire,andtookapuretonehearingthresholdtest(puretonethresholdsof50dB
orlowerwereaccepted).ParticipantswereseatedataMacintoshPowerBookcomputerandfittedwith
headphoneswithanattachedmicrophone(BeyerdynamicBT190).Theparticipantthenreadthe
instructions.Playbackofthe20speakerbabblewasinitiatedandcontinuedforthedurationofthe
experiment.

ThePsyScopeexperimentprogram(Cohen,MacWhinney,Flatt,&Provost,1993)wasusedto

runthemainexperiment.Thetaskbeganwith21practicetrialsandcontinuedwith198trialsinrandom
orderasthemainexperiment.Onenamewassubsequentlydroppedfromtheanalysisduetoanerrorin
recording.Oneachtrial,participantswereaskedtorepeatbackthenametheyhadheard.Spoken
responseswererecordedthroughthelaptopsbuiltinmicrophone.Aftercompletingthemain
experiment,participantsmovedtoanothercomputerandreadaloudthe198experimentalnamesas
theywerevisuallypresentedonacomputerscreen.Participantsratedtheirfamiliaritywitheachname
ona7pointscale(extremelyfamiliarextremelyunfamiliar).

Duringpilottestingonpracticingpharmacists,theseS/Nratiosproducederrorratesofroughly25%,50%,and
75%atthelow,mediumandhighS/Nlevels.
10

ErrorinSpokenMedicationOrders

ScoringSpokenResponses

SpokenresponsesweretranscribedintotheARPAbet(Jurafsky&Martin,2000).phonetic

alphabetbyanexperiencedlinguist(e.g.,Zyvoxwastranscribedas/Z1AYV2AAKS/,wherethe
numerals1and2indicatestresslevel).Responseswerescoredascorrectorincorrectbycomparing
thetranscribedresponsestothereferencetranscriptionsforeachofthe197stimulusnames.Because
variationinpronunciationmadeverbatimmatchingtothereferencetranscriptiontoostrictacriterion,
wedevelopedadditionalprocedurestocapturelegitimatepronunciationvariants.Thefirstwasa
computerprogramthatappliedgenerallyacceptedrulesforpronunciationvariationtothereference
pronunciations.Forexample,influentspeech,unstressedvowelsoundsarereducedtotheschwa
sound.(Schwaisashortneutralvowelsound,themostcommonvowelsoundinEnglish,e.g.thefirst
phonemeintheword/again/.)Responseswerescoredascorrectiftheycouldbeproducedbyapplying
thevariationrulestothereferencepronunciations.Evenafterapplyingtheserules,therestillappeared
tobelegitimatevariantsthatwerebeingscoredasincorrect.Sothelinguistexaminedallincorrectly
scoredresponses,identifiedthosedeemedtobelegitimatevariants,andprovidedlinguisticjustification
foreachcase.Intheend,aresponsewasscoredascorrectifitmatchedthereferencepronunciation
exactly,ifitcouldbeautomaticallygeneratedasarulegeneratedvariant,orifitwasrecognizedbyour
expertinphoneticsasalegitimatevariant.
AnalysisPlan

ThegoalofouranalysiswastoquantifythemaineffectsofFWNP,noise,frequencyand

familiarityonaccuracyinauditoryperception.DescriptiveanalysesweredoneusingSASversion9.1and
totestthehypotheses,mixedeffectslogisticregressionmodelswerebuiltwithSuperMix(Hedeker&
Gibbons,2008).

11

ErrorinSpokenMedicationOrders

Thedependentvariablewasaccuracy.Wordscorrectlyidentifiedwerescoredas1,andwords

incorrectlyidentifiedwerescoredas0.Theindependentvariableswere:(1)theFWNPscore,a
continuousvariableontheinterval0to1,reflectingthepredictedprobabilityofidentification;(2)signal
tonoiseratio,anordinalvariablewiththreelevels(2dB,+3dB,+8dB);(3)familiarity,anordinal
variablereflectingaparticipantssubjectivefamiliaritywiththename(rangingfrom1to7);(4)
prescribingfrequency,acontinuousvariablerepresentingthelog(base10)ofthemaximumfrequency
fromourmultiplesourcesofprescribingfrequencydata;(5)phonemefrequency,acontinuousvariable
representingthefrequencyofagivenconsonantorvowelinagivenpositionintheword,(6)biphone
frequency,acontinuousvariablerepresentingthefrequencyofatwophonemesequenceinagiven
positionintheword(Storker,2004).Thecontrolvariableswere(1)participantdemographics,including
age,gender,race,practicecontext,professionandyearsofexperience;(2)puretonethreshold,eight
continuousvariablesreflectingthesensitivityofaparticipantshearingineachearat500Hz,1kHz,2kHz
and3kHz;(3)length,anordinalvariablereflectingthenumberofphonemesintheword;and(4)trial,an
ordinalvariablerepresentingthesequentialpositionofagivenresponsewithinthesetof198
responses.

Totestourhypotheses,webuiltalogisticregressionmodelforthecombinedgroupof

clinicians(pharmacists,physiciansandnurses)andaseparatemodelforlaypeople,treatingthe
interceptsasarandomeffect.Wealsocarriedoutsubgroupanalysesforeachclinicalprofession,the
resultsofwhicharepresentedinselectedtablesandfigureswherespacepermits.Weidentifiedthe
correctscaleforeachindependentandcontrolvariablebyplottingthelogoddsoferrorasafunctionof
eachvariable.Iftheseplotswerelinear,termswereenteredaslinear.Iftheplotrevealedanobvious
nonlinearity,weselectedascaletofitthenonlinearformofthefunction(Hosmer&Lemeshow,1989;
Selvin,1996).WeusedKleinbaumsmethodofbackwardeliminationtodecidewhichvariablesto
includeinthefinalmodel(Kleinbaum,1994).Thismethodbeginswithafullmodelandproceedsto
12

ErrorinSpokenMedicationOrders

eliminateasmanytermsaspossible,usinglikelihoodratioteststodecidewhichtermscontribute
significantlytothemodelsfit.Allstatisticaltestsused=0.05.Finally,weexaminedthefitbetween
observedandpredictedaccuracyratesforeachofthe197stimulusnames.Observedratesweretaken
directlyfromthedata.Foreachparticipant,weusedtheparameterestimatesfromthefittedmodeland
covariatevaluesfromthedatatogenerateapredictedproportionofcorrectidentificationsforeach
nameaveragedacrossallparticipants.
Results

Eachofthe239participantsrespondedto197stimuli,producing47,083totalresponses.Mean

accuracyontheperceptiontaskwas32.27%(s.d.=7.94,range=12.18%49.75%,alsoseeTable5).
Roughly77%ofcorrectresponseswereidentifiedbyverbatimmatching,9.5%bycomputerscoringof
alternativepronunciationsand13.5%byexpertscoringofalternatives.Thiserrorrateisroughlytwo
ordersofmagnitudegreaterthanwhatonewouldexpectinrealworldpractice(Flynn,Barker,&
Carnahan,2003).Thetaskwasintentionallydesignedtobedifficultandtoproducehigherrorrates
because(a)wewereinterestedinstudyingtheerrorsthemselves,andwewantedalargesampleof
errorstoanalyze,and(b)duetostatisticalpowerconsiderations,thenaturalisticerrorrate(perhaps
0.13%)(Flynn,etal.,2003)wouldhavemadeitimpossibletodetectanydifferencesinerrorrateacross
experimentalconditions.Thetaskwasnotdesignedtoestimaterealworlderrorrates(thatisbest
achievedbydirectobservation).Rather,ourgoalwastounderstandthefactorsthataffectedtheerror
rateinataskthatwasanalogousto,butmoredifficultthan,therealworldtask.

Table1describesparticipantdemographics.Table2givesthemeansandstandarddeviationsof

continuouspredictorsforcorrectandincorrectresponsesaswellasresultsofbivariatetestsof
associationbetweeneachpredictorandthelogoddsofacorrectresponse.Table2providestheinitial
indicationofthebeneficialeffectsoffamiliarityandprescribingfrequencyonaccuracyforboth
cliniciansandlaypeople.Forclinicians,frequencyweightedneighborhoodprobability(FWNP)andword
13

ErrorinSpokenMedicationOrders

lengthwerealsoassociatedwithincreasedaccuracy.ForlaypeopleFWNPhadnoimpact,andlonger
nameswereactuallyperceivedlessaccuratelythanshorternames.Thenumberofphonemeshelped
cliniciansbecauseeachadditionalphonemeprovideddisambiguatinginformationthataidedthemin
discriminatingbetweensimilaralternativesinmemory.Forlaypeople,mostofwhomwereunfamiliar
withthestimulusnames,thetaskwasreallyabottomupidentificationtask,andadditionalphonemes
madethattaskharder.AsimilaranalysiscouldbemadeinrelationtoFWNP.FWNPpredictedclinician
performancebecauseFWNPmeasurestheextenttowhichanameisfreeofcompetitionfromsimilar
neighbors.Butsincelaypeoplelackedmentalrepresentationsformostofthesewords,FWNPwasnota
relevantmeasureforthem.Individualdifferencevariableslikehearingacuity,ageorexperiencehad
littleornoimpactonaccuracy(especiallyforclinicians),whereaspropertiesoftheenvironmentorthe
stimulusnamesdid.
Table12abouthere.

Table3givestheproportionofcorrectandincorrectresponsesinrelationtothenominal

predictors,aswellasresultsoftestsofthebivariateassociationbetweenpredictorsandaccuracy.For
clinicians,accuracymorethantripledfromthenoisiesttothequietestcondition.Inlaypeople,the
effectwasevenstronger.Forclinicians,gender,typeofname(brandvs.generic),raceandpractice
contextweresignificantlyassociatedwithaccuracyinbivariateanalyses,butmanyoftheseeffectswere
confoundedwithtypeofclinicianandwerenotsignificantinmultivariateanalyses.
Table3abouthere.

Figure1illustratesthepowerfuleffectoffamiliarityonaccuracy.Performanceonthemost

familiarnameswasroughlythreetimesbetterthanontheleastfamiliarnames.Thisisaconsequenceof
thewellknownwordfrequencyeffect,whichpredictsthatfamiliarwordswillbeperceivedmore
accuratelythanunfamiliarwordsdueeithertohigherrestingactivationlevelsortodecisionbiasesthat
14

ErrorinSpokenMedicationOrders

favorfamiliaritemsinmemory(Howes,1957).Figure2showstheequallydramaticeffectsofnoiseon
accuracy,againwithperformanceimprovingbyafactorofthreeforcliniciansandbyafactorofmore
than5forlaypeopleasS/Nratioincreasedfrom2dBto+8dB.Figure2alsoshowsthatwithoutnoise,
laypeopleperformedaswellaspharmacistsinthe+8dBcondition.Therewasacleargradientin
accuracy,withpharmacistsbeingmostaccurate,followedbyphysicians,nursesandlaypeople.Asmight
beexpected,performanceappearedtobedeterminedbyeachgroupsfamiliaritywithdrugnames
greaterfamiliarityledtohigheraccuracy.
Figures1and2abouthere.

Table4givestheparameterestimatesforthefinalrandomeffectlogisticregressionmodels.

Cliniciansandlaypeopleproduceddifferentpatternsofresults,presumablybecauseclinicianshad
lexicalrepresentationsformanyofthenames,butlaypeopledidnot.Forclinicians,thetaskinvolved
(bottomup)identificationand(topdown)discriminationamongsimilarcompetingalternatives.Forlay
people,itwasprimarilyabottomupidentificationtask.S/Nratiowasassociatedwithsignificantly
improvedaccuracyinparticipantsauditoryperceptionofdrugnames.Forclinicians,frequency
weightedneighborhoodprobabilitywasassociatedwithincreasedaccuracy.Nameswithfewerandless
frequentlyprescribedneighborswereheardmoreaccuratelythannameswithgreaternumbersofmore
frequentlyprescribedneighbors.Forbothlaypeopleandclinicians,familiardrugnameswereperceived
moreaccuratelythanunfamiliarnames,althoughtherelationshipwasnonlinearforclinicians.For
cliniciansbutnotforlaypeople,nameswithhighprescribingfrequencywereperceivedmoreaccurately
thannameswithlowprescribingfrequency.Forclinicians,accuracyincreasedasthenumberof
phonemespernameincreasedwhiletheoppositewastrueforlaypeople(forthereasondescribed
above).Forbothcliniciansandlaypeople,biphonefrequencywaspositivelyassociatedwithaccuracy.
Forclinicianstheeffectofbiphonefrequencywasmodifiedsomewhatbyphonemefrequency.Thus,the

15

ErrorinSpokenMedicationOrders

presenceofcommonsoundpatternsmadenameseasierrecognize.Forclinicians,S/Nratiointeracted
significantlywithfamiliarity,asdidphonemeandbiphonefrequency.

Cliniciansgotslightlybetteratthetaskastheycompletedmoretrials.Brandnamedrugswere

perceivedlessaccuratelybycliniciansthangenericnames,evenaftercontrollingfornamelengthand
numberofneighbors.Insubgroupanalyses(detailsnotshown)thiseffectwasrestrictedtophysicians.
Physiciansandnurseshadloweraccuracyscoresthanpharmacists.Forlaypeople,ageandhearing
acuitywereassociatedwithaccuracy.Forclinicians,onlyleftearpuretonethresholdat2000Hzwas
associatedwithaccuracy.
Table5abouthere.

Toassessgoodnessoffitofthemodel,wecomparedtheobservedandpredictedpercent

correctforeachofthe197drugnames.Therootmeansquareerrorofpredictionrangedfrom15.3%to
18.5%(seeTable5).Severalnameswererarelyidentifiedcorrectly(e.g.,sutilains,Kira,sparfloxacin,and
tromethamine),whileotherswererarelymissed(e.g.,hydrochlorothiazide,Zithromax,codeine).The
modelsaccountedforbetween32%and49%ofthevarianceinaccuracyattheleveloftheindividual
name.
Figure4abouthere.

Substitutionerrors.Themostcommontypeoferrorwasanincorrectpronunciationofthe

stimulusname(90%),butoneintenerrorswasasubstitutionerror,wheretheresponsecorresponded
toanotherrealdrugname.Substitutionsproducepotentiallyharmfulwrongdrugerrors.Modelsof
spokenwordrecognition,includingNAM,predictthatrarenameswillbemisheardascommonnames
butnotviceversa.Wetestedthishypothesis.Overwhelmingly,substitutionerrorswentinthedirection
ofthemorefrequentlyprescribedname.Therewere4692substitutionerrorsoverall.In2963(63.2%)of
theseerrors,thesubstitutednamehadahigherprescribingfrequencythanthestimulusname.In1411
16

ErrorinSpokenMedicationOrders

cases(30.1%),thesubstitutednamewasnotinourprescribingfrequencydatabases.Consideringonly
thecaseswithknownprescribingfrequency,errorswentinthedirectionofthemorefrequently
prescribeddrug90.31%ofthetime.Forclinicians,themeandifferenceinlogprescribingfrequency
betweenthesubstitutednameandthetargetnamewas2.40(s.d.=1.82),meaningthesubstitutedname
was,onaverage,prescribed250timesmorefrequentlythanthetarget.Forerrorsthatwentinthe
directionofthemorefrequentlyprescribedname,themeandifferenceinlogfrequencywas2.75.For
errorsthatwentinthedirectionofthelowerfrequencyname,themeandifferenceinlogprescribing
frequencywasonly1.22.Thissuggeststhatconfusionsgointhedirectionofthelesscommonnameonly
whentheprescribingfrequenciesarerelativelysimilar.Asthedifferenceinprescribingfrequency
increasessodoesthetendencyfortheerrorstogointhedirectionofthehigherfrequencyname(see
Figure3).
Discussion

Ourgoalwastoidentifyfactorsthataffectaccuracyinauditoryperceptionofdrugnames.

Resultsofourexperimentssupportedourthreespecifichypothesesandourgeneralmodelofauditory
perception:(1)Accuracy(forclinicians)wasinfluencedbythesimilarityneighborhoodofeachdrug
name(i.e.,bythesimilarityandprescribingfrequenciesofneighboringnames).Nameswithlesssimilar
andlesscommonlyprescribedneighborsweremoreaccuratelyperceivedthannameswithmoresimilar
andmorefrequentlyprescribedneighbors.Nameswithfewerandlessfrequentlyprescribedneighbors
weresubjecttolesscompetitionduringwordrecognitionandwerethereforeperceivedmore
accurately.(2)AccuracyincreasedasS/Nratioincreased.And(3)familiar,morefrequentlyprescribed
nameswereperceivedmoreaccuratelythanunfamiliar,lessfrequentlyprescribednames.

Someoftheseassociationsweremorecomplexthanwehadpredicted.Therelationship

betweenFWNPandaccuracywasquadraticforclinicians,andtherelationshipbetweenfamiliarityand
accuracywascubicforclinicians.Inbothcasesthisislikelybecausesomewords(thelowfamiliarity
17

ErrorinSpokenMedicationOrders

names)weresimplyunknowntotheparticipants.Theseunknownwordswereprocessedasiftheywere
nonwords,andtheeffectsofmanyofourpredictorsonwordsandnonwordsareknowntodiffer.For
analogousreasons,wesawinteractionsbetweenfamiliarityandotherpredictors(e.g.,S/Nratio,
phonemefrequency,andbiphonefrequency).Theserelationshipsneedtobeexploredmorethoroughly
insubsequentwork.

Ourmodelsaccountedforasubstantialamountoftheobservedvarianceinitemlevelaccuracy.

Webelievesuchmodelswouldbeusefultopolicymakersanddrugcompaniesastheyevaluatethe
confusabilityofnewandexistingdrugnames.Wefoundconfusionstobeasymmetrical,with
substitutionsoverwhelminglygoinginthedirectionofthemorefrequentname.Thus,whenpolicy
makersconsiderthepotentialforharmrelatedtoanameconfusion,theymustconsiderthedirectionof
theerror(i.e.,whichdrugwillbemistakenforwhich).Morefamiliarandmorefrequentlyprescribed
drugswilltendtohavelowererrorrates,butinthinkingaboutharm,thismustbeweighedagainsttheir
highernumberofopportunitiesforerror(Lambert,etal.,2003).
Limitations

Wemeasuredsubjectivefamiliarityaftertheparticipantscompletedtheauditoryperception

task.Therefore,itispossiblethatourmeasureofsubjectivefamiliaritymayhavebeeninfluencedby
experienceintheexperimentitself.Althoughpossible,weexpectthatthiseffect,ifitexistedatall,was
small,especiallyincomparisontothelongtermprimingeffectsoflifetimeexperience(orlackthereof)
withthesestimulusnames.Previousworkonsubjectivefamiliaritysuggeststhatitisanaccurate
measureoflifetimeexposuretowordsandthatitisbetterthanobjectivefrequencyforpredictingword
recognitionperformance(Balota,Pilotti,&Cortese,2001;Carroll,1971;Gernsbacher,1984).

Westudiedaconveniencesampleofrighthanded,nativeEnglishspeakingcliniciansandlay

people.Westudiedonly197drugnamesoutofperhaps11,000ormoredrugnamesinuseintheU.S.
18

ErrorinSpokenMedicationOrders

Generalizationstoothercliniciansandotherdrugnamesshouldbemadecautiously.Thelevelandtype
ofnoiseweusedmaynotreflectrealworkingconditions,especiallybecausethenoisewasofaconstant
typeandamplitude. 4 Realworldcontextsexperienceunpredictablenoiseofvaryingtypesand
intensities.Thelackofforeignlanguageaccents,distractions,interruptionsandofclinicalcontextwas
alsounrealistic.Thisworkshouldbereplicatedundermorerealisticconditions.
CONCLUSION

Objectivelymeasurablepropertiesofdrugnamescanbeusedtopredicttheirconfusability.The

abilitytoaccuratelyidentifyspokendrugnamesisinfluencedbysignaltonoiseratio,subjective
familiarity,prescribingfrequency,andthesimilarityneighborhoodsofdrugnames.Tominimizeerrors,
ordertakersshouldbeabletoincreasethesourcevolume,andshouldhavenoisecancelling
headphonesorquietareaswheretheycantakeorders.Althoughnotdirectlysupportedbythese
experiments,itisgenerallyagreedthatspokencommunicationofdrugnamescanbemadesaferby
usingstrategieslikereadback,spellingoutthename,providingtheindicationforthedrugorusingboth
brandandgenericnames(especiallyforphysicianswhoweremorelikelytomisperceivebrandthan
genericnames).Thefindingthatlaypersons,withnobackgroundnoise,achievedrecognitionscores
aboutequaltothoseachievedbyexpertcliniciansoperatingundermoderatesignaltonoiseratios,
underscorestheimportanceofreducinglocalandremotebackgroundnoiseandgivingordertakersthe
abilitytoincreasevoicesignalloudness.Sinceunfamiliardrugnamesaremorelikelytobemisperceived
thanfamiliarnames,itmaybepossibletoreducedrugnameconfusionsbyincreasingclinicians
familiaritywithawiderarrayofdrugnames.Itmayalsobepossibletoimproveperformancebyhaving
peoplelearnthedistinguishingpartsofsimilardrugnamesthroughrepeateddiscriminationtraining.

Neverthelessitmaybeofinteresttonotethatanumberoftheprofessionalscommentedthatthebabblenoise
wasrealistic.
19

ErrorinSpokenMedicationOrders

However,theeffectivenessofbothsuggestedinterventionscouldhaveunintendedconsequencesand
haveyettobeevaluated.Theexperimentsandmodelsdescribedaboveshouldproveusefulto
regulatoryagenciesanddrugmanufacturerswhomustevaluatetheconfusabilityofdrugnamespriorto
allowingthemonthemarket.

20

ErrorinSpokenMedicationOrders

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23

ErrorinSpokenMedicationOrders

Table1.Demographiccharacteristics
Variable
Age

Gender
Male
Female
Race
Asian
Pacific
Islander
Black
White
Multiracial
Other
PracticeContext
Hospital
Clinic
Retail
Community
Other

Pharmacists
(n=62)

Physicians
(n=74)

Nurses
(n=70)

LayPeople
(n=43)

39.1(10.7)

44.3(10.9)

43.2(7.7)

29.8(12.3)

26
36

3
1

40.9
58.1

4.8
1.6

50
24

16
0

67.6
32.4

21.9
0

1
69

1
0

1.4
98.6

1.4
0

11
32

0
3

25.6
74.4

0
7.1

5
50
1
2

7
13
33
9
0

8.1
80.7
1.6
3.2

11.3
21.0
53.2
14.5
0.0

2
54
0
1

6
61
0
0
7

2.7
74.0
0
1.4

8.1
82.4
0
0
9.5

0
66
1
2

69
1
0
0
0

0
94.3
1.4
2.9

98.6
1.4
0
0
0

11
24
4
1

26.2
57.1
9.5
0.2

24

ErrorinSpokenMedicationOrders

Table2.Mean(standarddeviation)ofcontinuousindependentvariablesforcorrectandincorrect
responses
Clinicians(N=206)
Variable

Incorrect

Correct

(n=26776)

(n=13806)

R500Hz

25.92 (8.32)

26.07 (8.60)

L500Hz

24.12 (10.91)

R1000Hz

LayPeople(N=33)
Incorrect

Correct

(n=5111)

(n=1390)

0.44

12.94 (4.74)

12.65 (4.87)

0.26

23.92 (10.53)

0.37

11.91 (4.56)

11.50 (4.63)

0.09

17.72 (7.10)

17.43 (7.06)

0.05

8.02 (5.93)

8.07 (6.35)

0.87

L1000Hz

16.03 (7.45)

15.86 (7.42)

0.26

6.92 (5.73)

6.45 (5.83)

0.14

R2000Hz

10.85 (8.75)

10.71 (8.17)

0.38

4.35 (6.41)

3.83 (6.40)

0.13

L2000Hz

10.89 (8.97)

10.64 (8.49)

0.15

4.66 (6.76)

4.83 (6.63)

0.57

R3000Hz

10.96 (10.47)

11.14 (10.12)

0.45

3.37 (8.19)

2.49 (7.94)

0.04

L3000Hz

11.72 (11.10)

11.73 (10.89)

0.95

5.20 (8.19)

4.97 (7.86)

0.65

PhonemeFreq.

-0.11 (1.19)

-0.01 (1.10)

0.00

-0.14 (1.21)

0.07 (1.01)

0.00

BiphoneFreq.

-0.14 (1.03)

0.04 (1.02)

0.00

-0.14 (1.03)

0.08 (1.01)

0.00

Age

42.43 (10.13)

42.18 (10.06)

0.25

30.62 (12.42)

30.41 (11.86)

0.81

Experience

14.79 (10.19)

14.63 (10.15)

0.42

Familiarity

2.73 (2.36)

4.57 (2.65)

0.00

1.61 (1.44)

2.63 (2.28)

0.00

FWNP

0.53 (0.34)

0.60 (0.36)

0.00

0.55 (0.35)

0.56 (0.35)

0.34

RxFrequency

3.14 (1.65)

3.94 (1.76)

0.00

3.37 (1.75)

3.58 (1.65)

0.00

No.Phonemes

8.06 (2.29)

8.25 (2.80)

0.00

8.25 (2.53)

7.67 (2.22)

0.00

121.95 (57.13)

123.62 (57.22)

0.01

99.40 (547.09)

100.22 (57.39)

0.63

Trial

Note.R500Hzisthelowestnumberofdecibelsatwhicha500Hztonecouldstillbeheardintheright
ear.L500Hzistheleftear,etc.FWNPisfrequencyweightedneighborhoodprobability.RxFrequencyis
thelog(base10)ofthenationalprescribingfrequencyofthestimulusnames.Mixedeffectslogistic
regressionmodelswerebuiltwithSupermixwithonlyaninterceptandoneindependentvariableinthe
model.PvaluescomefromWaldtestsontheparameterestimateforthevariableinquestion.Lay
resultsareforn=33layparticpantsintheconditionwithbackgroundnoise.Therewere197
25

ErrorinSpokenMedicationOrders

observationsforeachparticipant,sotherewere12,214pharmacistresponses,14,578physician
responses,and13,790nurseresponses.Seetextfordetails.

26

ErrorinSpokenMedicationOrders

Table3.Percentcorrectandincorrectresponsesbynominalcovariates

Variable

Clinicians(N=206)
%Cor. %Inc.

LayPeople(N=33)
%Cor.

%Inc.

0.0000

S/NRatio

0.0000

2dB

16.03

83.97

6.83

93.17

+3dB

36.10

63.90

21.32

78.68

+8dB

49.93

50.07

35.99

64.01

0.0000

Gender

0.31

Male

36.09

63.91

23.13

76.87

Female

32.78

67.22

20.91

79.09

0.0000

NameType

0.83

Brand

31.30

68.70

21.27

78.73

Generic

36.76

63.24

21.49

78.51

0.0000

Race

0.09

White

34.44

65.56

22.73

77.27

NonWhite

32.05

67.95

19.76

80.24

0.0000

Context

Hospital

30.28

69.72

Clinic

35.42

64.58

Retail

38.70

61.30

Other

36.88

63.12

Note.Probabilities(P)comefromWaldtestsonparameterestimatesgeneratedbySuperMixmixed
effectsregressionmodelswithonlyonepredictorvariableenteredatatime.Layresultsareforn=33lay
particpantsintheconditionwithbackgroundnoise.Adashindicatesthatvariblewasnotincludedinthe
analysis.

27

Pharmacists

ErrorinSpokenMedicationOrders

Physicians

Nurses

LayPeople

Figure1.Auditoryperceptionaccuracyasafunctionoffamiliarity.Foreachleveloffamiliarity,thedark
barrepresentsthepercentofincorrectresponsesasapercentofthetotalnumberofresponsesforthat
participantgroup.Thelightbarrepresentsthepercentofcorrectresponsesatthatfamiliaritylevel.The
linerepresentsthepercentcorrectatagivenleveloffamiliarity.Forlaypeople,dataareshownonly
fromparticipantsintheconditionwithbackgroundnoise.

28

ErrorinSpokenMedicationOrders

Figure2.Effectofsignalstrengthonaccuracyforpharmacists,physicians,nursesandlaypeople.Noise
wasplayedatmean65dBamplitudeforallparticipantgroups,exceptwherenotedforlaypeople.Sothe
threesignaltonoiseconditionscorrespondedto2dB,+3dBand+8dB.Laypeopleweretheonly
subgrouptestedwithoutnoise.

29

ErrorinSpokenMedicationOrders

Table4.Parameterestimatesforrandomeffectslogisticregressionmodelofaccuracyinauditory
perceptionforcliniciansandlaypeople

Variable

Clinicians(n=206)

OR(95%CI)

LayPeople(n=33)

OR(95%CI)

Intercept

0.21(0.150.30)

0.0000

0.03(0.10.8)

0.0000

S/NRatio(dB)

1.23(1.221.24)

0.0000

1.23(1.211.25)

0.0000

0.83(0.411.68)
0.31(0.061.60)
4.34(1.5112.53)

0.60
0.16
0.01

FWNP
FWNP2
FWNP3

RxFrequency
RxFrequency2

0.99(0.941.04)
1.02(1.011.02)

0.69
0.0000

Familiarity
Familiarity2
Familairity3

2.09(1.652.66)
0.83(0.780.90)
1.02(1.011.02)

0.0000
0.0000
0.0000

1.40(1.351.46)

0.0000

Num.Phonemes
Num.Phonemes2

0.82(0.780.86)
1.01(1.011.01)

0.0000
0.0000

0.92(0.890.94)

0.0000

PhonemeFreq.
BiphoneFreq.

0.73(0.680.78)
1.69(1.581.82)

0.0000
0.0000

1.29(1.201.37)

0.0000

0.995(0.9930.998)
1.04(1.031.06)
0.95(0.930.96)

0.0001
0.0000
0.0000

Nonwhite
Trial
Brand

0.79(0.700.89)
1.0009(1.00051.0013)
0.93(0.880.98)

0.0001
0.0000
0.01

Physician
Nurse

0.91(0.821.01)
0.66(0.590.74)

0.08
0.0000

1.11(1.041.17)
0.999(0.9980.999)

0.0007
0.002

0.96(0.940.99
1.03(1.011.05)
0.97(0.950.99)
1.02(1.001.04)
0.98(0.960.99)
1.02(1.001.04)

0.003
0.01
0.01
0.03
0.02
0.02

FamiliarityxS/NRatio
FamiliarityxPhonemeFreq.
FamiliarityxBiphoneFreq.

Age
Age2
R500Hz
R1000Hz
R2000Hz
L2000Hz
R3000Hz
L3000Hz

0.99(0.980.99)

30

0.0000

ErrorinSpokenMedicationOrders

Note.FWNP=frequencyweightedneighborhoodprobability.RxFrequencyisthelogbase10ofthe
maximumfrequencyobservedacross4differentprescriptiondatabases.S/Nratioisthesignaltonoise
ratio.Forrace,thereferencegroupwasandwhite(Caucasian).R500Hzisthelowestnumberofdecibels
atwhicha500Hztonecouldstillbeheardintherightear.L500Hzistheleftear,etc.Adashmeansthe
variablewasnotsignificantinthemodel.Superscriptnumbersareexponents,e.g.,FWNP2=FWNP
squared.Seetextfordetails.

31

ErrorinSpokenMedicationOrders

Table5.Summaryofauditoryperceptionresultsforpharmacists,physicians,nursesandlaypeople.
Variable

AllClinicians
(n=206)

34.23(6.82)
13.7149.75

17.23%

Pharmacists
(n=62)

39.14(5.83)
16.7549.75

18.5%

Physicians
(n=74)

34.46(5.52)
19.847.2

17.5%

Nurses
(n=70)

29.02(5.15)
13.7138.58

17.8%

LayPeople
(n=33)

21.38(5.36)
12.1830.46

15.3%

Accuracy(%)

Mean(s.d.)

Range
GoodnessofFit

Rootmean
squarederror

Mean
14.22%
15.5%
14.7%
14.6%
11.7%
absolute
error
0.47
0.49
0.48
0.42
0.32

R2predicted
vs.observed
SubstitutionErrors

Number(%of
4449(10.96)
1780(14.6)
1404(9.66)
1265(9.17)
243(3.73)
allresponses)

%ofincorrect
16.62
23.95
14.69
12.92
4.75
responses

No.with
3128
1266
975
887
153
knownfreq.

No.(%)in
2849(91.1)
1163(91.9)
883(90.6)
803(90.5)
114(74.5)
directionof
higher
frequency
name

Mean(s.d.)
2.40(1.80)
2.57(1.80)
2.27(1.76)
2.30(1.83)
1.54(2.06)
logfreq.
difference
between
targetand
substituted
name
Note.Forlaypeople,dataareshownonlyparticipantsintheconditionwithbackgroundnoise.

32

ErrorinSpokenMedicationOrders

Pharmacists

Physicians

Nurses

LayPeople

Figure3.Directionofsubstitutionerrorsasafunctionofdifferenceinlogprescribingfrequency.Thebar
chartisahistogramoffrequencydifferencesbetweenstimulusnamesandsubstitutednames.The
bottompartofeachverticalcolumnrepresentsthenumberoftimesthesubstitutednamewasless
frequentlyprescribedthanthestimulusname(leftaxis).Thetopportionrepresentsthenumberof
timesthesubstitutednamewasmorefrequentlyprescribedthanthestimulusname.Theline
representsthepercentofsubstitutionerrorswhereinthesubstitutednamewasmorefrequently
prescribedthanthestimulusname(rightaxis).Thegraphsshowthatwhenonenameismistakenfor
another,thesubstitutednameisalmostalwaysmorefrequentlyprescribedthanthenamewhichwas
misheard.Theprobabilityoferrorisnotasymmetricalfunctionofsimilarity.Relativelylowfrequency
namesareliabletobemisheardastheirhigherfrequencyneighbors,butnotviceversa.

33