The 8th annual national MEDMARX(R) Data Report released last month by the U.S. Pharmacopeia (USP) revealed that more than 1,400 commonly used drugs are involved in errors linked to drug names that look alike or sound alike. USP’s review revealed a near doubling since 2004 of the pairs of drug names that look or sound alike, from 1,750 pairs to 3,170 pairs.
According to findings in the MEDMARX report, 1.4% of the errors resulted in patient harm, including seven errors that may have caused or contributed to patient deaths. Medication errors are often the basis of medical malpractice cases.
The MEDMARX report includes the largest known list of look-alike/sound-alike drugs. The list is the only list based on reported medication errors. Due to widespread under-reporting of incidents, and because the database does not include every hospital in the United States, the study’s authors believe that the number of adverse events resulting from look-alike/sound-alike errors is actually understated.
Examples of the sound-alike names that can result in a mistake: Zantac, an ulcer medication, sounds confusingly similar to Xanax, a tranquilizer. Other examples: Zoloft, Zofran, Zocor, Zyrtec, Zantac, Ziac, Zetia, Zerit, Zestril and Zyprexa, to name a few.
Pharmaceutical companies are trying to alleviate some of the problems. The cholesterol reducer Lovaza, made by GlaxoSmithKline, was once known as Omacor, but it was frequently confused with the drug Amicar. In its report, the USP found in one instance a patient inappropriately received Lamictal, a bipolar drug, instead of the blood-pressure lowering medication Labetalol. Within days the patient was hospitalized with elevated blood pressure.
A similar survey by the FDA revealed that confusing drug nomenclature can have fatal consequences. In 2005, the agency reported an 8-year-old girl died after receiving methadone, a narcotic, instead of methylphenidate, an attention deficit medication.
In another case, a 19-year-old man showed signs of potentially fatal complications after he was given clozapine, a drug for difficult-to-treat schizophrenia, instead of olanzapine, another type of schizophrenia drug.
Another type of medication error involves administering a dosage that is higher or lower than what was prescribed. Last year, Dennis Quaids 2-week old twins were given 1,000 times the intended dosage of the blood thinner Heparin at Cedars-Sinai Medical Center. The babies were supposed to have received 10 units per millimeter of the anticoagulant to keep their IVs from clotting, but instead were given 10,000 units per millimeter.
In response to the findings, USP is calling on prescribers and pharmacists to include an “indication for use” on prescriptions. Indication for use is a phrase that signals why the patient is taking the drug (e.g. cough, infection, rash). To prevent medication errors, USP recommends that this powerful piece of information be conveyed at several points along the health care continuum.
Additionally, prescribers should use trustworthy decision-support tools to help ensure accuracy. Tools such as Epocrates, Lexi-Drugs, and others have been helpful in reducing potential medication errors, and the addition of MEDMARX look-alike/sound-alike data will make such tools even stronger. MEDMARX is an anonymous, Internet-accessible program used by hospitals and related institutions nationwide to report, track, and analyze medication errors.
Since its inception in 1998, MEDMARX has received more than 1.2 million reports of medication errors from more than 870 health care facilities across the U.S. MEDMARX is the largest nongovernmental, Internet- accessible database of medication errors in the U.S.
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