Healthy Skepticism Library item: 12659
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Publication type: news
Ricks D.
Boom in similar drug names fuels medicine mix-ups
Newsday.com 2008 Jan 29
http://www.newsday.com/news/health/ny-hsdrug0130,0,5434758.story
Full text:
Medication mix-ups have more than doubled since 2004, driven largely by a troubling proliferation of prescription drugs with confusingly similar names, according to a new report.
Examining records submitted by 870 hospitals to MEDMARX, a database run by the United States Pharmacopeia, researchers discovered glaring, and sometimes deadly, medication errors linked to sound-alike, look-alike medication names. USP is a nonprofit agency that sets standards on prescription and nonprescription drugs, working with the U.S. Food and Drug Administration as well as pharmaceutical companies.
In the new report, its eighth assessment of medication errors, USP researchers found that 1.4 percent of the mistakes resulted in harm, including seven errors that may have caused or contributed to the deaths of patients.
The research implicated 1,470 different drugs in errors associated with brand or generic names that looked or sounded similar. From this data, USP compiled an even longer list of 3,170 pairs of names that look or sound alike. This total is nearly double the 1,750 pairs that USP identified in its 2004 analysis.
“This is a hallmark report that really has galvanized the health care community,” said Darrell Abernethy, chief science officer at USP. He said the list has doubled because of the increasing number of drugs that are approved. USP researchers reviewed more than 26,000 records, he said.
Abernethy added that errors from sound-alike, look-alike drug names are a problem that spans the entire health care industry. “Currently about 15,000 new error reports are generated each month and entered into the database, so this is indeed a very robust database,” he said.
The report revealed that a child who was seen in an emergency room was prescribed Zyprexa, a schizophrenia drug, instead of the allergy medication Zyrtec. The child was rushed back to the ER after fainting, at which time the mix-up was discovered, the USP report said.
“This report brings a new dimension to USP’s list of look-alike and/or sound-alike drug names by providing additional evidence about the many ways in which easily confused names can lead directly to medication errors,” said Diane Cousins, USP’s vice president for health care quality and information.
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.
With MEDMARX, hospitals participate anonymously and voluntarily. Because the database does not include every hospital in the United States, the number of actual medication errors is probably higher, USP researchers say.
