Michael J. Gaunt, PharmD
Dr. Gaunt is a medication safety analyst
and the editor of ISMP Medication
Safety Alert! Community/Ambulatory
Care Edition.
As we start the New Year, let's
challenge ourselves to do more
to prevent drug name mix-ups.
Reports involving dispensing errors due
to drug name mix-ups are a regular topic
in this column and in many news stories
involving medication errors. Often, the
mix-ups are related to drug names that
look or sound alike, or to look-alike
packaging. It is not unusual that such
mix-ups lead to patient harm, yet the
vast majority of these mix-ups could be
prevented if the pharmacist knew the
indication for the medication.
Name Pair Confusion
Five different name pairs that had
been confused and led to dispensing
errors were reported in the inaugural
issue (September 2002) of the ISMP
Medication Safety Alert! Community/Ambulatory Care Edition alone. For
example, one article in that issue focused
on recommendations for preventing
mix-ups between Zyrtec (cetirizine)
and Zyprexa (olanzapine). At that time,
reports had been received from many
practice settings about such mix-ups.
In one reported case, a patient who was
given Zyprexa in error suffered a head
injury after losing consciousness.
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Another report described a previously
controlled psychotic patient who
accidentally received Zyrtec instead of
Zyprexa and then relapsed. Since that
time, in an effort to reduce errors, Eli
Lilly has changed the Zyprexa product
label to highlight the letter characters
that differ from Zyrtec. Eli Lilly also
has alerted practitioners to this issue
through direct mail campaigns and
journal advertisements. Still, ISMP has
continued to receive reports of this mixup,
including one from an emergency
department nurse who explained that
staff had treated a 7-year-old child who
had received 3 doses of Zyprexa 10 mg
instead of Zyrtec 10 mg after his prescription
was filled incorrectly at a local
pharmacy.
This is just one of many examples of
commonly confused drug names that
continue to cause mix-ups and patient
harm. (For ISMP's List of Confused
Drug Names, go to: www.ismp.org/Tools/confuseddrugnames.pdf.) Ideally,
drug names that are similar or might
contribute to confusion with existing
drug names would never be approved
for use in the marketplace. Although
many drug manufacturers and the FDA
test new drug names for safety, errorprone
drug names may be approved. One
example includes confusion between
Yaz (drospirenone 3 mg; ethinyl estradiol
0.02 mg) and Yasmin (drospirenone
3 mg; ethinyl estradiol 0.03 mg), which
was discussed in my June 2008 column
in Pharmacy Times.
Error Prevention Strategies
ISMP works to promote error prevention
strategies that prevent confusion.
Some of the lower leverage strategies
focus on human vigilance (education,
awareness, auxiliary labeling, patient
counseling, etc). Although often fairly
easy and inexpensive to implement,
these strategies alone may have limited
long-term effectiveness because
they rely on human intervention, which
may not occur. Unfortunately, these
are often the only strategies selected to
achieve change.
Higher leverage strategies that address
contributing factors inherent in
the health care delivery system (eg,
computerized prescribing, bar-code
scanning, and hard stops in computer
systems for commonly confused drug
names) are used less frequently because
they may be more difficult or expensive
to implement. For more information on
the impact of various error reduction
strategies, see my April 2007 column in
Pharmacy Times.
To prevent drug name mix-ups, we
have to change our focus and build
more powerful safety measures into our
systems rather than simply relying on
"fixing" individual behavior.
Inside the Issue
