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HPXXXX10.1177/0018578717715346Hospital PharmacyCohen and Smetzer

ISMP Medication Error Report Analysis

ISMP Medication Error Report Analysis

Hospital Pharmacy
2017, Vol. 52(6) 390-393
© The Author(s) 2017
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https://doi.org/10.1177/0018578717715346
DOI: 10.1177/0018578717715346
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Michael R. Cohen1 and Judy L. Smetzer1

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where
you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should
consider publishing accounts of errors in your newsletters and/or presenting them at your in-service training programs.
Your assistance is required to continue this feature. The reports described here were received through the Institute for
Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous.
Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown
below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.
org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the
information received and respects reporters' wishes as to the level of detail included in publications.

What's in a Generic Name? Clues
About the Drug's Use and Possible
Adverse Effects
Many health care professionals, particularly pharmacists,
know that they can use a drug's nonproprietary (generic) to
help position it among other drugs in the same therapeutic
class by recognizing drug name stems, a collection of short
name fragments, that have been embedded in the nonproprietary drug names. Because drugs in each of these therapeutic classes work on similar sites in the body and have
similar effects and side effects, the nonproprietary name
can help health care professionals understand how the drug
might be used clinically and alert them to possible adverse
effects often seen with drugs within the specific class of
medications. However, not all health care professionals
realize that nonproprietary drug names provide these very
important clues.

USAN Naming Process
Since 1961, the United States Adopted Names (USAN)
Council has been responsible for selecting simple, informative, and unique nonproprietary drug names based on pharmacological and/or chemical relationships.1,2 Pharmaceutical
companies must obtain a generic name is before bringing a
new drug to the market. Today, there are 5 members of the
USAN Council, including the American Medical Association,
United States Pharmacopeia (USP), American Pharmacists
Association, US Food and Drug Administration (FDA), and
a member at large. ISMP also has an important role with
USAN by identifying medication errors that have been tied
to nonproprietary drug names.

At the crux of the USAN naming process is the collection
of standard stems used as prefixes, suffixes, and infixes to
identify the pharmacologic property and/or chemical structure of the medication. Sometimes, the standard name stems
used for nonproprietary drug names can lead to name similarities that cause mix-ups among the various drugs with the
same stem. However, the stem helps position an unfamiliar
drug with others in a class and provides clues as to its use and
effects. For example, drugs ending in the stem -olol belong to
the class of drugs known as beta blockers. Some examples of
beta blockers available in the United States include atenolol,
bisoprolol, esmolol, metoprolol, and propranolol. Although
this class of drugs may be used to treat a variety of conditions, in general, a drug with an -olol stem in its generic
name is often used to treat heart failure, cardiac arrhythmias,
and hypertension and shares similar adverse effects like bradycardia and hypotension.
Another example is the group of drugs ending with the
stem -oxetine used for antidepressants (FLUoxetine type).
Examples of drugs with this name stem include vortioxetine
(TRINTELLIX), FLUoxetine (PROZAC), and PARoxetine
(PAXIL). These drugs are selective serotonin reuptake inhibitors. They work by increasing levels of the neurotransmitter
serotonin in the brain by blocking their reabsorption or reuptake. These drugs are used for various psychiatric disorders
such as depression, anxiety, and obsessive-compulsive disorder. They share many of the same side effects.
1

Institute for Safe Medication Practices, Horsham, PA, USA

Corresponding Author:
Michael R. Cohen, President, Institute for Safe Medication Practices, 200
Lakeside Drive, Suite 200, Horsham, PA 19044, USA.
Email: mcohen@ismp.org
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