Include Indication For Use to Avoid Rx Errors

The soaring numbers of commonly used drugs with sound-alike and look-alike names have prompted the U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors due to brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph.

“We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows health care professionals to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or sound-alike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular medications, such as lisinopril and enalapril, and central nervous system agents, such as trazodone and chlorpromazine.

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg—an iron replacement—was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg—an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors.

It would be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine.

The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins emphasized. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said, explaining that this also would help patients avoid confusion if they forget which vial is for which condition.

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. USP recommends the following:

▸ Consider the potential for mix-ups before adding a drug to your formulary.

▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.

▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.

▸ Prohibit verbal orders for sound-alikes that have been mixed up at your facility.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins concluded.

The concern is that this increase in look-alike products further raises the opportunity for error. MS. COUSINS

The soaring numbers of commonly used drugs with sound-alike and look-alike names have prompted the U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors due to brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph.

“We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows health care professionals to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or sound-alike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular medications, such as lisinopril and enalapril, and central nervous system agents, such as trazodone and chlorpromazine.

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg—an iron replacement—was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg—an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors.

It would be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine.

The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins emphasized. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said, explaining that this also would help patients avoid confusion if they forget which vial is for which condition.

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. USP recommends the following:

▸ Consider the potential for mix-ups before adding a drug to your formulary.

▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.

▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.

▸ Prohibit verbal orders for sound-alikes that have been mixed up at your facility.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins concluded.

The concern is that this increase in look-alike products further raises the opportunity for error. MS. COUSINS

The soaring numbers of commonly used drugs with sound-alike and look-alike names have prompted the U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors due to brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph.

“We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows health care professionals to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or sound-alike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular medications, such as lisinopril and enalapril, and central nervous system agents, such as trazodone and chlorpromazine.

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg—an iron replacement—was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg—an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors.

It would be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine.

The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins emphasized. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said, explaining that this also would help patients avoid confusion if they forget which vial is for which condition.

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. USP recommends the following:

▸ Consider the potential for mix-ups before adding a drug to your formulary.

▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.

▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.

▸ Prohibit verbal orders for sound-alikes that have been mixed up at your facility.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins concluded.

The concern is that this increase in look-alike products further raises the opportunity for error. MS. COUSINS