Drug Name Confusion: Preventing Medication Errors
By Carol Rados
An 8-year-old died, it was suspected, after receiving
methadone instead
of methylphenidate, a
drug used to treat
attention deficit disorders. A 19-year-old man showed signs of potentially
fatal complications after he was given
clozapine instead of
olanzapine, two
drugs used to treat
schizophrenia. And a 50-year-old woman was hospitalized after taking
Flomax, used to
treat the symptoms of an enlarged
prostate, instead
of Volmax, used to relieve bronchospasm.
In each of these cases reported to the
Food and Drug
Administration, the names of the dispensed drugs looked or sounded like
those that were prescribed. There have been others:
Serzone, an
antidepressant, for
Seroquel, used to
treat schizophrenia, and
iodine for Lodine,
a non-steroidal
anti-inflammatory drug.
Adverse events that can occur when drugs are dispensed as the wrong
medications underscore the need for clear interpretation and better
communication between the doctors who write prescriptions and the pharmacists
who fill them. The FDA says that about 10 percent of all medication errors
reported result from drug name confusion.
"These errors are not usually due to incompetence," says Carol A. Holquist,
R.Ph., director of the Division of Medication Errors and Technical Support in
the FDA's Office of Drug Safety. "But they are so underreported because people
are afraid of the blame." Errors occur at all levels of the medication-use
system, from prescribing to dispensing, Holquist says, which is why those people
who receive the prescriptions must take action, too. "Everybody has a role in
minimizing medication errors," she says.
The Problems
Medication errors can occur between brand names, generic names, and
brand-to-generic names like
Toradol and
tramadol. But
sometimes, medication errors involve more than just name similarities.
Abbreviations, acronyms, dose designations, and other symbols used in medication
prescribing also have the potential for causing problems.
For example, the abbreviation "D/C" means both "discharge" and "discontinue."
The National Coordinating Council for Medication Error Reporting and Prevention
(NCCMERP) notes that patients' medications have been stopped prematurely when
D/C--intended to mean discharge--was misinterpreted as discontinue because it
was followed by a list of drugs.
Illegible handwriting, unfamiliarity with drug names, newly available
products, similar packaging or labeling, and incorrect selection of a similar
name from a computerized product list, all compound the problem. And, although
some drug names and symbols may not necessarily sound alike or look alike, they
could cause confusion in prescribing errors when handwritten or communicated
verbally, according to the
United States
Pharmacopeia (USP).
For example, Holquist says that several errors have occurred involving mix-ups
with the oral diabetes
drug Avandia and
the anticoagulant
Coumadin. Although
they don't look similar when typed or printed, the names have been confused with
each other when poorly written in cursive. The first "A" in Avandia, if not
fully formed, can look like a "C," and the final "a" has appeared to be an "n."
The XYZs of Naming Drugs
Names are part of developing a new drug. And coming up with a catchy, snappy
moniker that distinguishes one drug from another isn't easy. For the most part,
drug companies want a name that will boost sales, while consumers long for some
indication from the name of what the drug does. The FDA, however, won't allow
names that imply medical claims, suggest a use for which a drug isn't approved,
or promise more than they can deliver.
Naming a drug can be as complicated as creating a rhythmic cacophony of
unpronounceable syllables and emphatic-sounding letters, such as C and P. Other
naming strategies include letters that when strung together sound like something
high-tech--think Zyprexa,
Lexapro, and
Xanax.
But whether it's the sound of certain letters that manufacturers like, or the
vision that a name conjures up, the FDA says that selection must take into
account concerns for reducing errors and for avoiding trademark infringement.
Because of today's tough trademark requirements, many drug companies are
turning to a growing industry of "naming" consultants for the task. These
consultants are charged with creating a unique name that will appeal to both
doctors and patients, particularly given the recent surge in direct-to-consumer
advertising.
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