Dermatologic look- or sound-alike medications

Journal of Drugs in Dermatology, Jan-Feb, 2004 by Loretta Gremillion, Daniel J. Hogan

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.