Confusion over Drug Names Leads to Medicine Errors

It’s hard to believe that a large number of tragic medicine errors could be avoided each year if medications were not confused with another drug or mispronounced when prescribed or administered. In the four years 2003-2006, there were 25,530 look-alike and/or sound-alike drug confusion medicine errors reported to drug error reporting systems. Drug labeling and packaging contributed to 7.8% of the look-alike and/or sound-alike medicine errors.

While the FDA reviews new drug names for potential confusion, it rarely requires name changes of existing drugs despite well documented instances where medicine errors have caused dangerous harm. And there are computerized prescribing and dispensing systems that could be extremely helpful in making patients safer, but they have not been widely adopted by hospitals or doctors.

A report issued by the U.S. Pharmacopeia (USP), the official "standards-setting" authority for medications and other health-care products sold in the United States, showed the relationship between drug names and medicine errors by reviewing more than 26,000 records. "If you pronounce it wrong, you may end up with the wrong drug," says Marilyn Storch, USP coordinator for all patient safety projects and the health care quality and information department. They found almost 1,500 different drugs implicated in medicine mistakes as a result of names that looked or sounded alike.

As Drugs Proliferate

"As drugs proliferate, they start to sound alike, like Celexa and Celebrex," said Dr. Kennedy, director of geriatric psychiatry at Montefiore Medical Center in New York City. The Celexa/Celebrex combination is a classic example, but there are others. Losec, for heartburn, was confused so often with Lasix, a diuretic, that the name was changed to Prilosec. But now that gets confused with Prozac, according to USP. And the Alzheimer's drug Reminyl was changed to Razadyne after mix-ups involving Amaryl, which lowers blood sugar. The medicine errors reportedly resulted in two deaths.

While there are several voluntary reporting systems that collect information about patient harm from medication, including FDA MedWatch, the ISMP Medication Errors Reporting Program (ISMPMERP), and Quantros MEDMARX. Some researchers believe that fewer than 1 in 100 medicine errors are reported to these voluntary systems.

Let’s hope that the current wave of healthcare reform provides better oversight and standardized means to prevent medicine mistakes. If you have been a victim, contact Seeger Weiss.

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