Experts say drugs with similar names are being mixed up in pharmacies.
Mixing up drug names because they look or sound alike is among the most common types of medical mistakes, and it can be deadly. Now new efforts are aiming to stem the confusion, and make patients more aware of the risk.
A major study by the U.S. Pharmacopeia, which helps set drug standards and promote patient safety said nearly 1,500 commonly used drugs have names so similar to at least one other medication that they’ve already caused mix-ups.
Now the group has opened a Web-based tool to let consumers and doctors easily check if they’re using or prescribing any of these error-prone drugs, and what they might confuse it with.
Try to spell or pronounce a few on the site and it’s easy to see how mistakes can happen. Did you mean the painkiller Celebrex or the antidepressant Celexa?
A more patient-oriented Web site is expected later this fall – a partnership of the nonprofit Institute for Safe Medication Practices and online health service iGuard.org, that will send users e-mail alerts about drug-name confusion.
A pilot program is being prepared through the Food and Drug Administration that would shift more responsibility to manufacturers to guard against name confusion. The goal is to spell out how to better test for potential mix-ups before companies seek approval to sell their products.
“There are so many new drugs approved each year, this problem can only get worse,” warns USP vice president Diane Cousins.
Estimates say at least 1.5 million Americans are harmed each year from a variety of medication errors, and name mix-ups are blamed for a quarter of them.
A company rarely changes a drug’s name after it hits the market, although it’s happened twice since 2005. The Alzheimer’s drug Reminyl now is named Razadyne, after mix-ups, including two reported deaths, with the old diabetes drug Amaryl. The cholesterol pill Omacor is now named Lovaza, after mix-ups with blood-clotting Amicar.
A doctor’s poor handwriting can be troublesome for a hurried pharmacist faced with alphabetized bottles on a shelf, making it easier to grab the wrong one.
Computerized prescriptions can cause problems as well. A doctor who e-prescribes still can click the wrong row on the alphabetized screen, picking the bone drug Actonel instead of the diabetes drug Actos.
Phone or fax a prescription, and static or smudged ink can turn the epilepsy drug Lamictal into the antifungal pill Lamisil.
A doctor might mean to prescribe a new drug but spells out a similar-sounding old one out of habit. Or the patient misspells or mispronounces one of his drugs, and a health worker assumes it’s the schizophrenia drug Zyprexa, not the antihistamine Zyrtec.
USP’s Cousins said they’ve had cases where a health care professional repeats what they think the patient’s on, and the patient thinks they must know what they’re talking about and agrees.
Cousins advises consumers to use the new web tool to check it against their current medications, so they know to pay more attention to confusing ones at refill time.
“Question the pharmacist if the tablets look different than last time – it might just be a new generic, or it might be the wrong drug altogether”, said pharmacist Marjorie Phillips, medication safety coordinator at MCGHealth, the Medical College of Georgia’s health system.
Doctors can also be asked to write the diagnosis on the prescription, a step that pharmacists told the Institute for Safe Medication Practices would help them prevent errors.
“What they consider most important is knowing why the medication is used,” says institute president Michael Cohen. “It would go a long way to interrupt a lot of these mix-ups.”
A doctor can write “for heart” next to “clonipine,” for example, and a pharmacist is less likely to grab similar-sounding gout pills.
But specialists are urging more research on another widely touted solution: Writing drug names in an eye-catching mix of upper- and lower-case letters.
Dr. Ruth S. Day, director of Duke University’s medical cognition laboratory, said it sometimes helps but can backfire. She found users of a heart drug got even more confused with it was written NIFEdepine – because the change made them pronounce it “KNIFE-duh-peen” instead of “nie-FEH-duh-peen.”
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