Drug Name Confusion: Let's resolve to do better
From the January 2006 issue
As we start the New Year, let’s also challenge ourselves to do more to prevent drug name mix-ups. Reports involving dispensing errors due to drug name mix-ups are a regular topic in this newsletter and in many news stories involving medication errors. In many cases, the mix-ups are related to look-alike drug names, sound-alike drug names, or look-alike packaging. It’s not unusual that such mix-ups lead to patient harm, yet the vast majority of these mix-ups could be prevented if the pharmacist knew the indication for the medication.
In our inaugural issue (September 2002) alone, we mentioned 5 different name pairs that had been confused and led to dispensing errors. For example, one article in that issue focused on recommendations for preventing mix-ups between ZYRTEC (cetirizine) and ZYPREXA (olanzapine). At that time, reports had been received from many practice settings about such mix-ups. In one reported case, a patient who was given Zyprexa in error suffered a head injury after losing consciousness. Another report described a previously controlled psychotic patient who accidentally received Zyrtec instead of Zyprexa and then relapsed. Since that time, in an effort to reduce errors, Eli Lilly has changed the Zyprexa product label to highlight the letter characters that differ from Zyrtec. Lilly has also alerted practitioners to this issue through direct mail campaigns and journal advertisements. Still, just before the New Year, we received a report from an Emergency Department nurse who explained that they had treated a 7-year-old child who had received 3 doses of Zyprexa 10 mg instead of Zyrtec 10 mg after his prescription was filled incorrectly at a local pharmacy.
This is just one of many examples of commonly confused drug names that continue to cause mix-ups and patient harm. (For ISMP’s List of Confused Drug Names, go to: http://www.ismp.org/Tools/confuseddrugnames.pdf .) Ideally, drug names that are similar or might contribute to confusion with existing drug names would never be approved for use in the marketplace. Although many drug manufacturers and FDA test new drug names for safety, error-prone drug names may be approved. (A recent example includes confusion between OMACOR [omega-3-acid ethyl esters] and AMICAR [aminocaproic acid], which was published in our November 2005 issue.) For this reason, ISMP works to promote error-prevention strategies that prevent confusion, which could cause patient harm. Some of the lower leverage strategies focus on human vigilance (education, awareness, auxiliary labeling, patient counseling, etc.). While often fairly easy and inexpensive to implement, these strategies alone may have limited long-term effectiveness because they rely on human intervention, which may not occur. Unfortunately, these are often the only strategies selected to achieve change. On the other hand, there are higher leverage strategies (computerized prescribing, bar-code scanning, hard stops in computer system for commonly confused drug names, etc.) that address contributing factors inherent in the healthcare delivery system. However, these are utilized less frequently because they may be more difficult or expensive to implement. To prevent drug name mix-ups, we have to change our focus and build more powerful safety measures into our systems rather than simply relying on “fixing” individuals. In our next issue, we will discuss the level of impact associated with various error-reduction strategies.
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