Look-alike, sound-alike drug names

Since the initial publication of the Joint Commission's Sentinel Event Alert in 1998, several issues have been devoted to the topic of medication errors and the identification, prevention, and reporting of specific types of medication errors either reported to Joint Commission as part of the sentinel event reporting system or identified by Joint Commission at the time of survey. Medication errors can occur at any point in the process of providing drugs to patients-prescribing, documenting, dispensing, administering-and many factors can contribute to medication errors, including poor handwriting, similar sounding or looking drug names, drug abbreviations, misinterpretation of labeling or packaging, miscalculations, lack of knowledge or skill, and incorrect administration. This issue of Sentinel Event Alert focuses specifically on medication errors resulting from confusing look-alike or sound-alike drug names and recommendations for minimizing risk and preventing potential errors.

With tens of thousands of brand name and generic drugs currently on the market, the potential for error due to confusing drug names is significant. "Health care professionals often report confusion between similar brand and generic names," says Diane Cousins, R.Ph., vice president, Practitioner and Product Experience department, U.S. Pharmacopeia. "Contributing to the confusion are complications such as illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labeling, and incorrectly selecting a drug from a computerized list," says Cousins. In fact, similar drug names, either written or spoken, account for approximately 15 percent of all reports to the USP Medication Errors Reporting program.

New names that are similar to existing names continue to be approved and medication errors continue to occur despite review before introduction to the market by a number of U.S. and international organizations, including pharmaceutical manufacturers, the U.S. Pharmacopeia, the International Nonproprietary Names Committee of the World Health Organization, the Food and Drug Administration, the U.S. Adopted Names Council, and the U.S. Patent and Trademark Office. "This ever-increasing number of confusing name sets represents such a broad range of products and therapeutic drug classes that every health care practitioner is vulnerable to making this type of error," says Cousins. "While similarly named products may not be perceived to pose a public health threat, USP has received reports of patient harm and fatalities that have occurred as a result of this problem."

In March, 2001, the USP released "Use Caution, Avoid Confusion," an updated list highlighting hundreds of confusing drug name sets and identifying more than 750 unique drug names that have been reported to the Medication Errors Reporting program. A poster and a laminated, quick-reference card are available for health care professionals free of charge from the USP by contacting USP's Practitioner and Product Experience department at (800) 487-7776.

While the FDA recently instituted an intensive risk analysis system for the review and evaluation of proposed proprietary drug names, and in fact rejects approximately one-third of all proposed names because of their potential for confusion, it is important for health care professionals to integrate systems and establish practices to reduce the possibility of ordering, dispensing or administering the incorrect drug.

At present, the Institute for Safe Medication Practices, USP and the FDA collect and track medication errors and make information available to health care providers and the public. "Coordinated efforts on the parts of these organizations and the reporting of medication errors has resulted in changes to the names of several commonly confused drugs," says Jerry Phillips, associate director, Medication Error Prevention, Office of Post Marketing Drug Risk Assessment, FDA. Information and alerts about confusing drug names and current initiatives to have confusing names changed may be obtained from the organizations' Web sites: www.ismp.org, www.usp.org, and www.fda.gov.

Risk reduction strategies

"To prevent errors, we must never rely solely on one's memory of problem name pairs. I strongly recommend that organizations routinely monitor information from the error reporting programs and then apply it."  --Michael Cohen President, Institute for Safe Medication Practices"

"To prevent errors, we must never rely solely on one's memory of problem name pairs," says Michael Cohen, M.S., FASHP, president, Institute for Safe Medication Practices. "I strongly recommend that organizations routinely monitor information from the error reporting programs and then apply it. For example, through careful formulary selection of alternative medications without nomenclature problems or through the use of interactive reminders in computer systems or auxiliary reminder labels on product containers." Other suggestions for minimizing the risk of errors include:

• Do not store problem medications alphabetically by name. Store such identified medications out of order, or in an alternate location.
• Provide or ask for both the generic and brand names of drugs for medication orders in order to provide patients and staff with information to avoid unintentional duplication.
• Write the purpose of the medication on the prescription. This inexpensive and efficient method to minimize errors helps the pharmacist in screening the medication order for proper dose, duration, and appropriateness, and it may also enable the pharmacist to intervene when multiple prescribers unknowingly order duplicative therapy for the same patient. It also minimizes the risk of confusion due to look-alike names of medications as well as the risk of misinterpretation due to poorly handwritten orders.
• Develop a policy for taking verbal or telephone orders. For example, when taking verbal drug orders, clearly repeat the name of the drug, the dosage ordered, and request or provide correct spelling. This is particularly important for sound-alike drugs. The National Coordinating Council for Medication Error Reporting and Prevention recently released comprehensive recommendations to reduce medication errors associated with verbal prescription orders. The recommendations are on the NCC MERP web site at www.nccmerp.org.

Provide the generic and brand name on all medication labels. Joint Commission standards in all programs (e.g. TX.3.5.1 in Comprehensive Accreditation Manual for Hospitals) require that all dispensed medications are appropriately and safely labeled using a standardized method in the most ready-to-administer form possible to minimize opportunities for error. This includes having both the generic name and, when different from the generic name, the brand name of the drug on the medication order. Surveyors will evaluate if the drug name on the medication order, medication label, and nursing MAR are the same. Providing both names on the label assures consistency between the documents and helps to prevent misinterpretation of orders.

Provide patients with written information about their drugs including the brand and generic names. Inquire if the prescribed drug is a routine medication and withhold medications that the patient questions or does not recognize.

Recommendations

Joint Commission standards for hospitals, ambulatory, and behavioral health organizations (e.g. TX.3.1 in Comprehensive Accreditation Manual for Hospitals) require that organizations maintain a list of medications that are always available within the organization (i.e. a formulary). Organizations must develop and follow criteria for selecting drugs that are stocked within an institution (i.e. added to the formulary), and one of the required criteria in the intent of the standard that must be considered is the potential for medication errors. Sound-alike names and similar labeling of generic products should be considered in determining the formulary selection of products. When look-alike and sound-alike drugs are allowed on the formulary, or are ordered on a non-formulary basis, they should be identified as being medications at "high risk" for potential error and extra steps should be taken to assure safety in ordering, dispensing and administering such products.

Organizations should review their policies and procedures regarding medication use to reduce the high potential for error from look-alike and sound-alike drugs, as well as other common sources of misinterpreted medication orders, and institute appropriate risk reduction strategies from the list above.

Please route this issue to appropriate staff within your organization. Sentinel Event Alert may only be reproduced in its entirety and credited to the Joint Commission on Accreditation of Healthcare Organizations.

Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies the most frequently occurring sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future.

During the on-site survey of accredited organizations, JCAHO surveyors assess the organization's familiarity with and use of Sentinel Event Alert information. Organizations are expected to (1) review each Sentinel Event Alert, (2) consider the suggestions, as appropriate to the organization's services, and (3) implement the suggestions, or reasonable alternatives, or provide a reasonable explanation for not implementing relevant changes.

Please route this issue to appropriate staff within your organization. Sentinel Event Alert may only be reproduced in its entirety and credited to the Joint Commission on Accreditation of Healthcare Organizations.

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