Accupril

Abstract

Medication errors contribute substantially to patient injury and death, with 25% of these errors attributed to drug names that look or sound alike. This article was written to heighten the awareness of dermatologists and related health care professionals of confusing dermatologic drug names and includes a table of 166 look- and sound-alike drug names. Measures to decrease medication errors due to confusing drug nomenclature in dermatology are suggested in order to maximize patient safety.

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Look- or sound-alike medications

Many drug names look or sound alike. Name confusion is to blame for 12 to 25% of errors voluntarily registered in the USA by health care professionals and patients (1,2). Confusion exists about generic and brand names, affecting over 60 look- and sound-alike medications prescribed frequently by dermatologists. According to the May 2003 Internal Medicine World Report, one frequent error is the confusion of Accupril for Accutane (3). Recent restrictions on Accutane prescribing should help preclude future errors for these two medications. Knowledge of such errors can help the physician understand and manage some cases of unexpected side effects or nonresponse to a customarily effective medication.

Drugs with similar orthographic (spelling) and phonologic (sound) qualities are most likely to appear in national error reports (1). Drugs with indistinguishable doses, dosage forms, and routes of administration further add to potential misunderstanding (4). Medication errors are particularly serious when neonates and small children are involved (5).

These medication errors contribute greatly to patient injury and health care cost, as highlighted in a recent Institute of Medicine (IOM) report. Medical errors account for 44,000 to 98,000 deaths annually and are the eighth leading cause of death in the United States. This mortality rate ranks above the annual mortality of motor vehicle accidents, breast cancer, or AIDS (3,6,7). The American economy loses an average of $23 billion annually due to preventable medical errors, $11 billion of which are health industry costs (6,7). The number of errors that occur in the outpatient setting are expected to greatly exceed those that take place within institutions and may contribute to many hospital admissions (3,7). The IOM supported the organization of a new agency, the Center for Patient Safety, to improve patient safety through instituting a research plan, creating national goals, and distributing yearly reports to the government on patient safety. Other IOM recommendations included creation of safety committees by every medical society to formulate a patient safety syllabus, promulgate safety information through all proven medical communication channels, and pool resources with the Center for Patient Safety to create error feedback loops targeted to localities. The American Academy of Dermatology has designated the Quality of Care Committee with the responsibility of examining the IOM report and identifying methods to decrease medical mistakes in order to maximize patient safety (7).

The true magnitude of errors and injuries due to look- and sound-alike drug names is difficult to estimate. It is believed that most errors are reported only if death or serious injuries result. The Institute for Safe Medication Practices estimates that of the 1200-1500 yearly reports they receive, 25% are due to confusing drug names. It is estimated that since only 1-2% of events are reported, the number of injuries or deaths from drugs that look and sound alike may exceed 10,000 annually (8). Fifteen percent of all communication to the USP Medication Errors Reporting Program between January 1, 1996 and December 31, 2000 involved drug name confusion (9). Most hospitals and health care professions have implemented measures to reduce medication errors, such as double-checking labels and dosage calculations, but mistakes still occur (8).

Why are so many confusing drug names still surfacing on the market? The answer involves many issues regarding drug name approval. First, the growing number of drugs approved for use contributes to the problem. Forty-eight percent of the prescription drugs available today have only been on the market since 1990 (8). According to the Institute for Safe Medication Practices, physicians must contend with 17,000 trade and generic names for drugs in the United States (10). There are numerous organizations involved in naming a drug, all with different goals. The International Nonproprietary Name and the United States Adopted Names Council promote names that are meaningful to health professionals. One example is the standard suffix "-mab" added to monoclonal antibodies, such as infliximab. The US Pharmacopeia requires names in accordance with established nomenclature. The US Patent and Trademark Office desires names that will not encroach on the commercial interests of existing trademarks. The FDA endorses names that maximize patient safety. Drug companies champion brand names that create brand loyalty through easy recognition and recall in the United States as well as in other countries.

The acceptability rules set for proposed drug names, however, are unclear and subjective (2). Colquitt and Phillips (Drug Topics. April 2001) claim that the Office of Postmarketing Drug Risk Assessment under the FDA uses computer-assisted analysis when evaluating proposed drug names, while Knaggy and Stein (Am J Health-Syst Pharm. Nov 2001) state that only a few companies have accounted for human factors in the evaluation process (8,11). Human factors are "the characteristics and limitations of human attention, perception, memory, judgment, decision-making, and motor control." (1) Many companies have shied away from incorporating these human factors, however, as this screening may increase rather than decrease corporate liability because it establishes culpable knowledge8. Finally, society has no practical method to change drug names which contribute considerably to medication errors, although drug manufacturers may voluntarily change a drug name, once a problem is realized (2,12). For example, Merck Sharp and Dohme changed Lose to Prilosec to preclude a mix-up with Hoechst-Roussel's Lasix (12).

What steps can physicians take to reduce medication errors due to confusing drug names? Physicians should be aware that 40% of medication errors occur at the drug ordering stage (13). One obvious solution is education about medications with similar nomenclature. Below is a table of dermatologic medications and non-dermatologic medications that may be confused in the clinical setting (Table 1). Doctors should write prescriptions neatly or use a computer for order entry to insure legibility. Dr. Subramanian Hariharan, director of the neurology residency program at the New Jersey Neuroscience Institute, has stated that 16% of physicians have unreadable handwriting (13). New electronic prescribing software, such as ePocrates and Allscripts, can be operated with handheld computers, which may avert prescribing mistakes. The use of computerized systems for order entry can eliminate two out of every three medication errors (14).

There are additional steps a doctor can take. Health care professionals who practice within the United States are of various ethnic and geographic backgrounds, with different pronunciations for drug names. Avoid verbal orders whenever possible to prevent confusion; if this is unavoidable, spell out the drug name (13,15,16). Write both the brand and generic names on prescriptions and include the diagnosis or the indication of the prescribed drug to eliminate dispensing errors (4,13,16). For medications frequently prescribed, use pre-typed prescriptions or ink stamps (13). In order to increase patient safety, the American College of Physicians is now providing classes dealing with this issue and urging physicians to attend. As medical errors are often attributed to a malfunction of the system used in an office setting, physicians are taught to examine their working environments to identify ways to reduce mistakes (3) as a practical quality improvement practice.

Risk reduction strategies should involve each member of the health care team. Hospital organizations should account for confusing drug names with similar nomenclature or packaging when choosing products for their formulary. When the procurement of such error-prone medications is unavoidable, extra steps should be performed to guarantee maximum patient safety in the prescription, dispersal, and administration of such drugs (17). Pharmacists should directly receive the physician's order to avoid unnecessary transcription steps (16). ePhysician, a handheld software program, allows physicians to directly send out prescriptions to patients' pharmacies (10). Pharmacists and nurses need to work diligently at dispensing the correct drug and be prepared to make inquiries if confusion exists (4). One suggestion to control dispensing errors is to store drugs with similar names or packages in different locations in the pharmacy (17). Patients should review each medication with the pharmacist, including the indication, side effects, and instructions (13). They should be proactive and contact their physician should a question arise (3).

Conclusion

Confusion among similar drug names will continue to be a problem, but problems can be identified and steps taken to help protect the patient. Currently, the FDA does not utilize a validated computer system which accounts for human factors to eliminate drugs with similar nomenclature (11). Pharmaceutical companies continue to resist change, fearing increased complexity, cost, and regulations for drug approvals (8). Heavy work loads due to lowered reimbursements and mismanaged care require health care professionals to be vigilant in prescribing and dispensing look- and sound-alike medications. Handheld computers may help to reduce the number of medication errors (10). Methods for monitoring and reporting medication errors should be enhanced, focusing on avoidable occurrences. Reporting should be anonymous and non-punitive in order to encourage robust participation. All medication errors should be reported to the US Medication Errors Reporting Program at 1-800-23-ERROR or at www.USP.org (15). Reporting remains the key element to uncover weaknesses and highlight pervasive problems which need improvement (14). Organizations and practices should frequently observe error reports and apply this knowledge in order to reduce medication errors in a timely fashion (17). With diligence and incorporation of some changes, we can help ensure the safety of our patients.

References:

1. Lambert BL, Chang KY, Lin SJ. Immediate free recall of drug names: Effects of similarity and availability. Am J Health-Syst Pharm 2003; 60(2):156-68.

2. Lambert BL, Lin SJ, Chang KY, Gandhi SK. Similarity as a risk factor in drug-name confusion errors. Medical Care 1999; 37(12):1214-25.

3. Schieszer J. Preventing Medical Errors and Improving Patient Safety. Internal Medicine World Report 2003; 18(5):1.30.

4. LeBelle MJ. Drug names and medication errors: Who is responsible? Can Med Assoc J 1993; 149(7):941-3.

5. Children's Hospital Boston. Children at Greater Risk for Potentially Harmful Medication Errors Despite Comparable Overall Medication Error Rates in Pediatric and Adult Hospitals 2001 April [cited 2003 Jun 17]. Available from URL: http://web1.tch.harvard.edu/pressroom/2001/april24.html

6. The Agency for Healthcare Research and Quality. Translating Research Into Practice, Reducing Errors in Health Care [cited 2003 Jun 9]. Available from URL: www.ahcpr.gov/research/errors.htm

7. The American Academy of Dermatology Association. Washington Report: Call to reduce medical errors, improve patient safety impacts dermatologists. 2000 Mar [cited 2003 Jun 6]. Available from URL: www.aadassociation.org/old/washReports/mar00_washrep.html

8. Kenagy JW, Stein GC. Naming, labeling, and packaging of pharmaceuticals. Am J Health-Syst Pharm 2001; 58(21):2033-41.

9. U.S. Pharmacopeia. USP Quality Review: Use caution--avoid confusion. 2001 Mar [cited 2003 Jun 6]: 76. Available from URL: http://www.usp.org/reporting/review/

10. Braus, P. Want to avoid drug errors? New software can help. ACP-ASIM Observer 2001 Apr [cited 2003 Jun 9]. Available from URL: http://www.acponline.org/journals/news/apr01/avoiderrors.htm

11. Holquist C. Phillips J. FDA Safety Page: How FDA reviews drug names. Drug Topics 2001 Apr [cited 2003 Jun 9]. Available from URL: www.fda.gov/cder/drug/MedErrors/reviewDrugNames.pdf

12. Teplitsky B. Avoiding the hazards of look-alike drug names. Nursing 1992; 22(1):60-1.

13. Darves B. Seven simple steps to prevent outpatient drug errors. The June ACP Observer [cited 2003 Jun 9]. Available from URL: www.acponline.org/journals/news/jun03/drug_errors.htm

14. President Bill Clinton. Remarks by the President on Medical Errors 2000 Feb 22 [cited 2003 Jun 11]. Available from URL: www.ahrq.gov/wh22200rem.htm

15. Croft. Carol. Adverse drug events and medication errors: lessons learned at the sharp end. Dallas: University of Texas Southwestern Medical Center, 1999.

16. Teplitsky B. Beware look-alike, sound-alike drugs! Michigan Medicine 1981; 80(20):367-8.

17. Joint Commission on Accreditation of Healthcare Organizations. Look-alike, sound-alike drug names. Sentinel Event Alert 2001 May: (19):1-4.

LORETTA GREMILLION MD AND DANIEL J HOGAN MD

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER SHREVEPORT, LOUISIANA

ADDRESS FOR CORRESPONDENCE:

Loretta Gremillion MD

LSU Health Center

1501 Kings Highway

Shreveport, Louisiana 71130

Phone: (318) 675-5054

Fax: (318) 675-4977

COPYRIGHT 2004 Journal of Drugs in Dermatology
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