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 Abstract
Medication errors contribute substantially to patient injury
and death, with 25% of these errors attributed to drug names
that look or sound alike. This article was written to heighten
the awareness of dermatologists and related health care professionals
of confusing dermatologic drug names and includes a table
of 166 look- and sound-alike drug names. Measures to decrease
medication errors due to confusing drug nomenclature in dermatology
are suggested in order to maximize patient safety.
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Look- or sound-alike medications
Many drug names look or sound alike. Name confusion is to
blame for 12 to 25% of errors voluntarily registered in the
USA by health care professionals and patients (1,2). Confusion
exists about generic and brand names, affecting over 60 look-
and sound-alike medications prescribed frequently by dermatologists.
According to the May 2003 Internal Medicine World Report,
one frequent error is the confusion of Accupril for Accutane
(3). Recent restrictions on Accutane prescribing should help
preclude future errors for these two medications. Knowledge
of such errors can help the physician understand and manage
some cases of unexpected side effects or nonresponse to a
customarily effective medication.
Drugs with similar orthographic (spelling) and phonologic
(sound) qualities are most likely to appear in national error
reports (1). Drugs with indistinguishable doses, dosage forms,
and routes of administration further add to potential misunderstanding
(4). Medication errors are particularly serious when neonates
and small children are involved (5).
These medication errors contribute greatly to patient injury
and health care cost, as highlighted in a recent Institute of
Medicine (IOM) report. Medical errors account for 44,000 to
98,000 deaths annually and are the eighth leading cause of death
in the United States. This mortality rate ranks above the annual
mortality of motor vehicle accidents, breast cancer, or AIDS
(3,6,7). The American economy loses an average of $23 billion
annually due to preventable medical errors, $11 billion of which
are health industry costs (6,7). The number of errors that occur
in the outpatient setting are expected to greatly exceed those
that take place within institutions and may contribute to many
hospital admissions (3,7). The IOM supported the organization
of a new agency, the Center for Patient Safety, to improve patient
safety through instituting a research plan, creating national
goals, and distributing yearly reports to the government on
patient safety. Other IOM recommendations included creation
of safety committees by every medical society to formulate a
patient safety syllabus, promulgate safety information through
all proven medical communication channels, and pool resources
with the Center for Patient Safety to create error feedback
loops targeted to localities. The American Academy of Dermatology
has designated the Quality of Care Committee with the responsibility
of examining the IOM report and identifying methods to decrease
medical mistakes in order to maximize patient safety (7).
The true magnitude of errors and injuries due to look- and
sound-alike drug names is difficult to estimate. It is believed
that most errors are reported only if death or serious injuries
result. The Institute for Safe Medication Practices estimates
that of the 1200-1500 yearly reports they receive, 25% are
due to confusing drug names. It is estimated that since only
1-2% of events are reported, the number of injuries or deaths
from drugs that look and sound alike may exceed 10,000 annually
(8). Fifteen percent of all communication to the USP Medication
Errors Reporting Program between January 1, 1996 and December
31, 2000 involved drug name confusion (9). Most hospitals
and health care professions have implemented measures to reduce
medication errors, such as double-checking labels and dosage
calculations, but mistakes still occur (8).
Why are so many confusing drug names still surfacing on the
market? The answer involves many issues regarding drug name
approval. First, the growing number of drugs approved for
use contributes to the problem. Forty-eight percent of the
prescription drugs available today have only been on the market
since 1990 (8). According to the Institute for Safe Medication
Practices, physicians must contend with 17,000 trade and generic
names for drugs in the United States (10). There are numerous
organizations involved in naming a drug, all with different
goals. The International Nonproprietary Name and the United
States Adopted Names Council promote names that are meaningful
to health professionals. One example is the standard suffix
"-mab" added to monoclonal antibodies, such as infliximab.
The US Pharmacopeia requires names in accordance with established
nomenclature. The US Patent and Trademark Office desires names
that will not encroach on the commercial interests of existing
trademarks. The FDA endorses names that maximize patient safety.
Drug companies champion brand names that create brand loyalty
through easy recognition and recall in the United States as
well as in other countries.
The acceptability rules set for proposed drug names, however,
are unclear and subjective (2). Colquitt and Phillips (Drug
Topics. April 2001) claim that the Office of Postmarketing
Drug Risk Assessment under the FDA uses computer-assisted
analysis when evaluating proposed drug names, while Knaggy
and Stein (Am J Health-Syst Pharm. Nov 2001) state that only
a few companies have accounted for human factors in the evaluation
process (8,11). Human factors are "the characteristics
and limitations of human attention, perception, memory, judgment,
decision-making, and motor control." (1) Many companies
have shied away from incorporating these human factors, however,
as this screening may increase rather than decrease corporate
liability because it establishes culpable knowledge8. Finally,
society has no practical method to change drug names which
contribute considerably to medication errors, although drug
manufacturers may voluntarily change a drug name, once a problem
is realized (2,12). For example, Merck Sharp and Dohme changed
Lose to Prilosec to preclude a mix-up with Hoechst-Roussel's
Lasix (12).
What steps can physicians take to reduce medication errors
due to confusing drug names? Physicians should be aware that
40% of medication errors occur at the drug ordering stage
(13). One obvious solution is education about medications
with similar nomenclature. Below is a table of dermatologic
medications and non-dermatologic medications that may be confused
in the clinical setting (Table 1). Doctors should write prescriptions
neatly or use a computer for order entry to insure legibility.
Dr. Subramanian Hariharan, director of the neurology residency
program at the New Jersey Neuroscience Institute, has stated
that 16% of physicians have unreadable handwriting (13). New
electronic prescribing software, such as ePocrates and Allscripts,
can be operated with handheld computers, which may avert prescribing
mistakes. The use of computerized systems for order entry
can eliminate two out of every three medication errors (14).
There are additional steps a doctor can take. Health care
professionals who practice within the United States are of
various ethnic and geographic backgrounds, with different
pronunciations for drug names. Avoid verbal orders whenever
possible to prevent confusion; if this is unavoidable, spell
out the drug name (13,15,16). Write both the brand and generic
names on prescriptions and include the diagnosis or the indication
of the prescribed drug to eliminate dispensing errors (4,13,16).
For medications frequently prescribed, use pre-typed prescriptions
or ink stamps (13). In order to increase patient safety, the
American College of Physicians is now providing classes dealing
with this issue and urging physicians to attend. As medical
errors are often attributed to a malfunction of the system
used in an office setting, physicians are taught to examine
their working environments to identify ways to reduce mistakes
(3) as a practical quality improvement practice.
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