Chapter 6. The Role of Drug Names in Medication Errors

Cohen, Michael R.; Domizio, George Di; Lee, Robert E.

doi:10.21019/9781582120928.ch6

Cited by 4 publications

(7 citation statements)

References 5 publications

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“…Medicines with similar‐sounding names, and drug names that look alike, have led to a number of serious errors, and continue to threaten patient safety in spite of error‐prevention measures adopted by licensing agencies and various healthcare systems [1,2] . Currently, licensing agencies employ a variety of pre‐approval tests to determine the vulnerability of new drugs to similar name confusion.…”

Section: Introductionmentioning

confidence: 99%

Incorrect drug selection at the point of dispensing: a study of potential predisposing factors

Anto

Barlow

Oborne

et al. 2011

International Journal of Pharmacy Practice

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Section: Introductionmentioning

confidence: 99%

Incorrect drug selection at the point of dispensing: a study of potential predisposing factors

Anto

Barlow

Oborne

et al. 2011

International Journal of Pharmacy Practice

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“…For example, Galanter and colleagues examined the use of indication alerts at the time of computerized physician order entry and found that some errors were averted. 12 Manufacturers use "tall-man" lettering to differentiate sections of a medication name on the medication's packaging, labeling, and bottle to decrease the confusion (eg, ARIPiprazole and RABEprazole), 20 though the effectiveness of this methodology has not been clearly demonstrated in real-world settings. 21,22 The strengths of our analysis include the large size of the Sentinel System and the ability to deploy readily available analytic tools to facilitate efficient identification and review of potential LASA errors.…”

Section: Discussionmentioning

confidence: 99%

“…For example, Galanter and colleagues examined the use of indication alerts at the time of computerized physician order entry and found that some errors were averted . Manufacturers use “tall‐man” lettering to differentiate sections of a medication name on the medication's packaging, labeling, and bottle to decrease the confusion (eg, ARIPiprazole and RABEprazole ), though the effectiveness of this methodology has not been clearly demonstrated in real‐world settings …”

Section: Discussionmentioning

confidence: 99%

Identification of potential drug name confusion errors in the Sentinel System

Cocoros

Haynes

Her

et al. 2019

Pharmacoepidemiology and Drug

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Purpose In July 2015, the US Food and Drug Administration (FDA) published a drug safety communication regarding errors in prescribing and dispensing of the antidepressant Brintellix (vortioxetine) and the antiplatelet Brilinta (ticagrelor) that arose due to proprietary drug name confusion. Brintellix is indicated for major depressive disorder; Brilinta is indicated to reduce cardiovascular death, myocardial infarction, and stroke in patients with acute coronary syndrome or history of myocardial infarction. Brintellix was renamed to Trintellix in May 2016. Using Brilinta and Brintellix as a proof‐of‐concept feasibility use case, we assessed whether drug name confusion errors between the pair could be identified in electronic health care data via the combination of a claims‐based algorithm and limited manual claims data review. Methods Using data from the Sentinel System, we defined potential errors as Brintellix users without an on‐ or off‐label indication for Brintellix, without a dispensing for a drug with the same indications as Brintellix, and with an on‐ or off‐label indication for Brilinta between −365 and +30 days after index Brintellix dispensing; the reverse was done for Brilinta. We manually reviewed claims profiles of potential cases. Results We identified 27 (0.1%) potential errors among 21 208 Brintellix users; 16 appeared to be likely errors based on claims profile review. Fifty‐one (0.3%) of the 16 779 Brilinta users were identified as potential errors, and four appeared to be likely errors. Conclusions A claims‐based algorithm combined with manual review of claims profiles could identify potential drug name confusion errors, and narrow down likely errors that warrant further investigation.

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“…Common pharmacy-based strategies to avoid SALA confusion include placing warning stickers or auxiliary labels on medication bottles or boxes to heighten attention to confusable medications, storing SALA medications in nonadjacent locations, requiring an additional verification step (by a second staff or pharmacy member), and conducting “failure modes and effects analyses” of medications considered for formulary inclusion. 8 Barcoding medications for inventory control and clinical decision support in the form of computerized alerts during computer prescriber medication order entry are common informatic-based strategies. 10 Organizations such as The Joint Commission mandate health care facilities desiring accreditation to proactively prevent errors with SALA medications they stock, dispense, and administer.…”

Section: Introductionmentioning

confidence: 99%

“…6,7 Numerous strategies and polices have been used to reduce the risk of SALA confusion. 1,8,9 Manufacturers and health care providers use "tall-man" lettering to differentiate various sections of a medication name (eg, ZyPREXA and ZyrTEC) to decrease confusion. 8 Health care providers are encouraged to read back verbal medication orders and use both brand and generic names on verbal, written, and electronic prescriptions.…”

Section: Introductionmentioning

confidence: 99%

Sound-Alike Look-Alike Confusion and Matching Medication Product Attributes: Simulated Case-Control Studies

Her

Toh

2019

Ann Pharmacother

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Background: Sound-alike look-alike (SALA) medication confusions harm as many as 250 000 Americans annually. Most preventive strategies focus on medication name similarities. Objectives: To evaluate the association between matching medication product attributes and SALA confusion. Methods: We simulated 20 000 case-control studies using the Institute for Safe Medication Practices’ List of Confused Drug Names as case pairs and 4 randomly selected control pairs per case pair from the First DataBank MedKnowledge (FDBM) database. We extracted 7 product attributes for each medication from the FDBM database. We used logistic regression models to estimate the associations between matching product attributes and SALA confusion. The models included a series of univariate (unadjusted) models, a model that adjusted for all product attributes, and a model that further adjusted for medication name similarity measures. Results: Medications with a matching product attribute had increased odds of SALA confusion in the univariate analyses (odds ratio [OR] = 4.2 to 55.5). When we simultaneously adjusted for all attributes, the associations of matching package unit, package unit size, formulation, strength, therapeutic class, and manufacturer with SALA confusion were attenuated but remained elevated (OR = 1.5 to 26.5), whereas the direction of association between matching route and SALA confusion reversed (OR = 0.8). These associations persisted on adjustment for medication name similarity measures. Conclusions and Relevance: This study is the first to evaluate the association between matching medication product attributes and SALA confusion with a control group. Having matching product attributes increased the odds of SALA confusion. SALA risk reduction strategies should consider product attributes.

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Chapter 6. The Role of Drug Names in Medication Errors

Cited by 4 publications

References 5 publications

Incorrect drug selection at the point of dispensing: a study of potential predisposing factors

Incorrect drug selection at the point of dispensing: a study of potential predisposing factors

Identification of potential drug name confusion errors in the Sentinel System

Sound-Alike Look-Alike Confusion and Matching Medication Product Attributes: Simulated Case-Control Studies

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