Vir Vikram Sharma M.Pharm. PhD (Pursuing)

Assistant Manager,In-Charge Pharmacy

DMC&H, Ludhiana, PunjabE-mail ID - vir_vikram17@yahoo.com virvikram76@gmail.com

Contact No.- +91-98157-86666

DAYANAND MEDICAL COLLEGE AND HOSPITAL

DEFINITION Some proprietary (brand name) and non-

proprietary names (generic name) sound or appear to be similar to other drugs when written or spoken.

These confusing drug names are one of the main causes of medication error. There are many sound and look alike drugs that would result in medication error. These errors may cause harm or even death to patients.

According to the results from United States Pharmacopoeia, around 1400 commonly used medications were involved in such errors. 

A group of medicines that have similar actions often have similar sounding brand names. The generic medicine is one that contains identical amounts of the same active ingredient, in the same strength and in the same dosage form.

When doctor writes a prescription they will nominate the medicine to be used –usually the originate brand name for the drug required.

Certain drugs have names that may appear similar when carelessly written; liable to confusion. Problems are likely if the strengths and doses of the two preparations are similar.

Doubts should be resolved by checking with the prescriber.

Most cases, mistakes have occurred, because the item was dispensed without a second thought. A large number of them have similar sounding or similar looking names, which is a reason for major concern among the prescribing physicians.

All these factors should clearly be borne in mind by the drugs controller while a brand name is approved. Therefore no two drugs should differ by an alphabet, syllable, suffix or prefix. There should be absolute clarity and differentiation of any two drugs whether the name are spoken or written

ORIGIN OF THE PROBLEM

SOURCE OF ERROR The main reasons for improper dispensing of

confusing brand names, may be due to negligence or due to lack of knowledge of registered pharmacist or due to less number of pharmacist during rush hours. When brand names of two or more drugs are similar.

Faulty dispensing would result from one of the following situation: Illegible handwriting of the prescribing physician

(reading &/or writing error). Incorrect dispensing by the pharmacist due to over

sight (similar looking name). Incorrect reading of the brands name by the patient

while ordering the medicine by phone, which is a common practice in some cities in this country (similar sounding name)

ERROR PRONE DRUG PAIRS Error prone medication pairs that can easily cause confusion while

prescribing, dispensing and administration/consumption were sorted out. Also real life experiences of medication errors and near misses due to error prone drug pairs were collected from the doctors and the dispensers.

1. LASA drugs-Similar brand names, different generic composition (Category I)

2. LASA drugs- Similar brand names, same generic composition (Category II)

3. LASA drugs- Similar brand names with additional letter (Category III)

4. LASA drugs- Similar brand names of the Antibiotics group (Category IV)

5. LASA drugs- Same drug, different Dosage forms (Category V)

6. LASA drugs- Same drug, different release characteristics (Category VI)

7. LASA drugs- Same brand name, different composition, different country (Category VII)

8. LASA drugs- Generic Drug pairs (Category VIII)

CONCEPTUAL FRAMEWORK TO REDUCE ERROR

Drug product inserted into complex care environment.

Drug product interacts with care environment and care processes in identifiable (often surprising) and predictable fashion.

These interactions will be determined by specific product characteristics and specific care processes

Errors occur in predictable ways! Allows risk assessment Allows risk reduction Allows error prevention

RISK FOR ERROR AND ADE

Error producing conditions Likelihood of error occurring Environment and processes of care Drug(s) involved Patient characteristic(s) Nature and type of error

ANY OR ALL CHARACTERISTICS OF A DRUG PRODUCT CAN INCREASE OR DECREASE RISK, AND MUST BE CONSIDERED IN RISK ASSESSMENT: Generic name, brand name Dose, strength(s), dose form, packaging Route, frequency, instructions Storage requirements Indications, patient population Likely care environment Other

The medical care “vortex”

Drug product

ERROR

IMPLICATIONS FOR RISK REDUCTION AND SAFETY ENHANCEMENTS

Predictable nature of errors allows risk assessment and reduction.

Predictable nature of errors allows product design which can enhance safety.

All drug product characteristics must be considered in risk assessment and prevention.

Care environment and processes must be considered in risk assessment and prevention.

Drug names, labels and packaging are major contributors to medication errors

Risk for error is determined by both drug product characteristics and the care system processes.

Risk assessment must include multiple drug characteristics (not just names)

Risk of error within care system often readily apparent

The predictable nature of errors provides opportunity for product naming and design which reduces risk and enhances safety.

POSSIBLE SOLUTIONS1. Identification of LASA medications: Create the

awareness of look-alike and sound-alike medicines in the prescribers; if possible provide a detailed list of drug names pairs in the local market

2. Prescriber’s role: Try to use legible handwriting while prescribing, keeping in mind as if one was writing bank cheques. Writing trade names (UPPER CASE) accompanied by generic names, dosage form, strength, directions and indication for use when possible.

3. Pharmacist’s/dispenser’s role: Provided that there is dose and other details in the prescriptions he/she should make use of his/her knowledge to identify the drug prescribed. In case of uncertainty in medicine names, they should not hesitate to consult the prescribing doctor before dispensing

4. Patient’s role: Literate patients can themselves check if the dispensed product is the same as prescribed. Patients who cannot read and write should better consult other sources for verification before taking the medicines.

5. Hospital’s or institution’s role: Provide education on potential LASA medicines. continuing professional development for health-care professionals and annually review the list of LASA medicines used in the institution. Try and reduce the medical transcription by the nursing staff and rather initiate dispensing only against a proper prescription by a licensed doctor. Use of printed order or electronic prescribing. the less important drug in the LASA pair can be removed.

6. Manufacturer’s and regulatory agency’s role: The manufacturers and regulatory agencies both should work together hand in hand to avoid confusion right at the time of naming their products.

PREDICTABLE PROBLEMS: Insulin brand names

•Humulin “Log” ordered instead of Humulin-L (Lente).•Nurse thought Humalog” was to be given.

NAMES AND LABELS: NOVOLOG IS “REGULAR” (“R” )INSULIN,

RIGHT?

DOSAGE FORM NAMES: OxyContin and MSContin

DOSAGE FORM NAMES:

Just a matter of time……

XR

LEGIBILITY AND DRUG NAMES

Capoten or Cozaar?

Protonix or Protamine?

Unasyn or Vancomycin?

TECHNOLOGY-DRUG PRODUCT INTERFACE: Levophed for Lopressor

WHY DOSE, ROUTE, FREQUENCY AND INDICATION ARE IMPORTANT:

Tricor for Tracleer Error detected because dose was different

Error NOT detected because dose was the sameProscar in a

female??

EXAMPLES AMGIT (Metronidazole) ANXIT (Alprazolam) ALASPAN (Loratadine) ALSPAN (Hyoscine butyl Br.) LEVOZIN (Levocetrizine) LIVOGEN (Iron) ENTEXIN (Ofloxacin) INFEXIM (Cefixime) TOZAAR (Losartan) TAZAR

(Piperacillin+Tazobactam) CETIL (Cefuroxime) CETIN (Cetirizine) AMTAS-10 (Amlodipine) ASTAT-10 (Atorvastatin) FLUNAZ (Fluconazole) FLUNAR (Flunarizine) PIOZ (Pioglitasone) PAAZ (Alprazolam) DAMOXY (Amoxycillin) DIAMOX (Acetazolamide) UMERAN (Diclofenac sodium) UMINORM (Metoclopramide)

EXAMPLES Epitab Phenytoin 100 mg Epitan Phenobarbitone 60 mg Ceftab Cefuroxime 250 mg Ceftas Cefixime 200 mg Wormnil Mebendazole 100 mg Wormonil Albendazole 400 mg Aquamide Furosemide 50 mg/Spironolactone

20 mg Aquazide Hydrochlorothiazide 12.5 mg

WHAT IS TALL MAN LETTERING?• It is an error-prevention strategy used as part

of a multi-faceted approach to reduce the risk of look-alike and sound-alike medicine name confusion and errors.

• It is a typographic technique that uses selective capitalisation to help make similar-looking medicine names easier to differentiate.

• Its purpose is to help select or supply the right medicine.

HOW DOES IT WORK?Tall Man lettering combines lower- and upper-case letters to highlight the differences between look-alike and sound-alike medicine names, like fluOXETine and fluVOXAMine, making them easier for the eye to distinguish.

WHAT COULD TALL MAN LETTERING BE USED ON?

• electronic drop-down medicine lists • automated dispensing cabinet screens • SMART pumps • computer-generated pharmacy labels• medicine shelf labels• pre-printed order sheets

ON THE CLOSING NOTE It is very important that we circulate the list of confusing

brand names among the practicing doctors, pharmacists and also to the drug manufacturers. Preventing confusion between already marketed products typically involves collecting voluntary reports of names involved in confusion errors, posting warnings and alerts both electronically and in areas where drugs are used.

The fear of malpractice lawsuits and public embarrassment has made the physicians and nurses reluctant to report medication errors. It is more important to create the open environment that encourages the reporting of errors than to develop less meaningful comparative error rates.

One possible approach to improving medical error reporting involves the use of anonymous standardized reporting systems. This type of system should also enable internal tracking, trending and comparative analyses. We need to have such systems in India.

Thank you