Drug Topics - March 10, 2008 - (Page HSE1) www.drugtopics.com MARCH 10, 2008 DRUG TOPICS HSE 1 HEALTH-SYSTEM EDITION USP report shows drug mix-ups on the rise, jeopardizing patient safety Michael Barbella T he number of drugs with similar-sounding names how difficult it is to distinguish between drugs that nearly doubled over the past four years, triggering sound alike: an order for 500 mg of Ferro-Sequel (an thousands of medication errors that in some in- over-the-counter iron replacement) was transcribed as stances were fatal, a new report concludes. “Serrosequel 500 mg” and the order was read as the anMore than 1,400 commonly used drugs are involved tipsychotic Seroquel (quetiapine, AstraZeneca). in errors linked to drug names that look or sound alike, Another mix-up cited in the report involved the simaccording to the 8th annual national MEDMARX Data ilar-sounding drugs Anexsia and Arixtra (fondaparinux Report released recently by the U.S. Pharmacopeia. sodium, GlaxoSmithKline). A doctor’s order to disconBased on the 1,470 drugs involved in medication errors, tinue Anexsia (a pain medication) was mistakenly read USP compiled a list of 3,170 pairs of names that look or by a pharmacist as an order to discontinue Arixtra (an sound alike—a figure that is nearly double the 1,750 anticoagulant). The report blames the mistake on the pairs identified in USP’s 2004 report. poor quality of the faxed order. The mistake was not According to Diane Cousins, R.Ph., USP’s VP of caught right away, and the patient missed several doses healthcare quality and information and co-author of the of his anticoagulant, the report stated. MEDMARX report, “The nation will now be able to The authors of the MEDMARX report said some of access the most comprehensive list of similar names that the mix-ups can be easily remedied, as long as preis based on actual reports of errors, and, for the first scribers, pharmacists, and consumers work together. time, a list that further delineates the errors’ effect on pa- THE AUTHOR is a writer based in New Jersey. tient outcomes.” USP compiled this list of look-alike, soundDrugs by therapeutic class associated alike drugs from 26,000 incidents of patients rewith the greatest number of ceiving the wrong medication between 2003 and lookalike/sound-alike drug pairs 2006. In 1.4% of those cases, a patient was harmed; however, USP researchers believe that Number of number to be “understated at best.” Contained Drug name (Therapeutic class) drug pairs in this year’s list are the 10 most popular drugs Cefazolin (antimicrobials) 15 sold in the United States in 2006, including LipLisinopril (cardiovascular medications) 13 itor (atorvastatin, Pfizer) and Singulair (monEnalapril (cardiovascular medications) 12 telukast sodium, Merck). Prednisone (hormones/synthetics/modifiers) 12 USP researchers attributed the rise in drug name Trazodone (Central nervous system agents) 12 mix-ups to a variety of factors, including an increase Metronidazole (antimicrobials, dermatological agents, genitourinary medications) 11 in the number of medicines approved by the Food Zestril (cardiovascular medications) 11 & Drug Administration and the gradual aging of Accupril (cardiovascular medications) 10 the nation’s population. Cefepime (antimicrobials) 10 “The communication of these medications can Cefotaxime (antimicrobials) 10 be marred by a bad cell phone connection or by faxChlorpromazine 10 es of poor quality,” Cousins noted. “[Mix-ups] can Diazepam (Central nervous system agents) 10 also happen because of similar packaging. Drugs Labetalol (cardiovascular medications) 10 can have the same dosage and be contained in the Levothryoxine (hormones/synthetics/modifiers) 10 same type of bottle. There are becoming fewer ways Prinivil (cardiovascular medications) 10 to distinguish drugs from one another.” Source: U.S. Pharmacopeia’s 8th Annual MEDMARX Data Report This is particularly true of medications that sound alike. The report provides an example of just http://www.drugtopics.com
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