Too many look-alike, sound-alike drug names
Voluntary reporting underestimates mistakes
Nearly 3,200 pairs of U.S. approved generic and brand drug names look or sound enough alike that health care workers mix up the medications. That's the finding of new research from the United States Pharmacopeia (USP), which reviewed more than 26,000 records in two USP-associated medication error reporting programs for 2003-2006. The analysis also found that patients might have been harmed, including seven mistakes that might have contributed to or resulted in death, by 1.4% of the mistakes attributed to look-alike and sound-alike drugs.
USP vice president Diane Cousins, RPh, said the number of mistakes "is probably understated at best," given that the programs reviewed involve the voluntary reporting of mistakes.
Some 26,092 records examined came from more than 670 health care facilities participating in USP's MEDMARX® program, while another 512 records came from the medication errors reporting program run by USP and the Institute for Safe Medication Practices. Less than 5% of the records described circumstances or events that had the capacity to cause a mix-up but did not result in one.
Of the more than 25,000 mix-ups that actually occurred, 65% originated in the dispensing phase of the medication-use process, according to the report. The report said that because all drugs pass through a pharmacy, pharmacy personnel "have the greater number of opportunities for error" with medications whose names look-alike or sound-alike.
The records on errors involving look-alike or sound-alike drug names identified pharmacy technicians as contributing the initial error in 38.5% of the cases, making them the category of staff most often mentioned. Pharmacists made the initial error 23.7% of the time, and the responsible health care worker was not identified in some 1% of the records.
Nearly 3,200 pairs of U.S. approved generic and brand drug names look or sound enough alike that health care workers mix up the medications. That's the finding of new research from the United States Pharmacopeia (USP), which reviewed more than 26,000 records in two USP-associated medication error reporting programs for 2003-2006.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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