Drug Name Confusion: Preventing Medication Errors (cont.)

FDA health professionals also are requested to interpret both written prescriptions and verbal orders through weekly in-house studies, in an attempt to simulate the prescription-ordering process. Holquist says that these studies are a valuable tool used in every review of proposed brand names. It is important, she adds, to be able to detect any potential sound-alike, look-alike confusion with proprietary names before a new drug application is approved.

Other efforts strongly encouraged for physicians include writing prescriptions more clearly, printing in block letters rather than writing in cursive, avoiding the use of abbreviations, and indicating the reason for the drug.

According to the FDA, pharmacists can help by keeping look-alike, sound-alike products separated from one another on pharmacy shelves, by avoiding stocking multiple product sizes together, and by verifying with the doctor information that is not clear before filling a prescription.

The FDA encourages pharmacists and other health professionals to report any actual or potential medication errors to the agency's MedWatch Adverse Event Reporting System online at www.fda.gov/medwatch/, by phone at (800) 332-1088, or by fax at (800) 332-0178. Caller identification is kept confidential and is protected from disclosure by the Freedom of Information Act.

Examples of Error-Prone Drug Information

Abbreviations Intended Meaning Misinterpretation Correction
Right ear, left ear,
each ear
OD, OS, OU (right eye, left eye, each eye)
Spell out "right ear," "left ear," "each ear"
"IV" or "intrajugular"
Spell out "injection"
TIW or tiw
3 times a week
"3 times a day" or "twice in a week"
Use "3 times weekly"
Dose Designations
Trailing zero after decimal point (1.0 mg)
1 mg
10 mg if the decimal point is not seen
Do not use trailing zeros for doses expressed in whole numbers
Abbreviations with a period following (mg. or mL.)
mg, mL
The period is unnecessary and could be mistaken as the number 1 if poorly written
Omit period and use mg, mL
Drug name and dose run together (especially problematic for drug names ending in "L" such as Tegretol300 mg)
Tegretol 300 mg
Tegretol 1300 mg
Place adequate space between the drug name, dose, and unit of measure
For three days
"3 doses"
Use "for three days"
/ (slash mark)
Separates two doses or indicates "per"
Number 1 (e.g., "25 units/10 units" misread as "25 units and 110" units)
Use "per" rather than a slash mark to separate doses
Use "and"

Institute for Safe Medication Practices

Reducing Drug-Name Medication Errors

Here's a list of steps you can take:

  • Know the name and strength of prescribed drugs before leaving the doctor's office
  • Insist that the doctor include the purpose of the medication on the prescription
  • Ensure that a refill is what it should be
  • Tell your doctor of any medical history changes.

Source: www.fda.gov

Last Editorial Review: 11/10/2005