Similar drug-name pairs nearly double 2004 tally

Including the indicated use when writing or filling a prescription can reduce look-alike, sound-alike drug mix-ups, experts say.

By Kevin B. O'Reilly, AMNews staff. April 14, 2008.

One physician's faxed order to discontinue hydrocodone, marketed as Anexsia, was misread by the pharmacist as an order to discontinue Arixtra, an anticoagulant. Another doctor intended to electronically order clonidine, an antihypertensive, but accidentally ordered the sedative clonazepam because both appeared as "CLON" on the computer screen.

These are just two of the 3,170 pairs of drug names that look or sound alike and can result in medication errors. They were found in a recent U.S. Pharmacopeia review of more than 26,000 patient records submitted over three years by 870 health care organizations. That total is nearly double the 1,750 similarly named drug pairs identified in a 2004 report issued by USP, a Rockville, Md.-based nonprofit standards-setting organization.

The more than 30,000 drug-name mix-ups included in the January 2008 USP report harmed patients 1.4% of the time, with seven patient deaths attributed to mistakes. USP leaders and other experts said including the indicated use for a medication could prevent such problems.

"Errors resulting from look-alike, sound-alike drugs are a problem that spans the entire health care system," USP chief science officer Darrell Abernethy, MD, PhD, said in a statement. "By recording and communicating not only the name of the drug, but also what it is being used for, prescribers, pharmacists and consumers can work together to dramatically reduce these types of medication errors."