Watch out for drug names that look, sound alike

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Watch out for drug names that look, sound alike

By LAURAN NEERGAARD, AP Medical Writer Mon Sep 1, 1:53 PM ET

WASHINGTON - Take the generic drug clonidine for high blood pressure?

Double-check that you didn't leave the drugstore with Klonopin for

seizures, or the gout medicine colchicine.

Mixing up drug names because they look or sound alike — like this trio

— is among the most common types of medical mistakes, and it can be

deadly. Now new efforts are aiming to stem the confusion, and make

patients more aware of the risk.

Nearly 1,500 commonly used drugs have names so similar to at least one

other medication that they've already caused mix-ups, says a major

study by the U.S. Pharmacopeia, which helps set drug standards and

promote patient safety.

Last week the influential group opened a Web-based tool to let

consumers and doctors easily check if they're using or prescribing any

of these error-prone drugs, and what they might confuse it with. Try

to spell or pronounce a few on the site — http://www.usp.org — and

it's easy to see how mistakes can happen. Did you mean the painkiller

Celebrex or the antidepressant Celexa?

Due out later this fall is a more patient-oriented Web site, a

partnership of the nonprofit Institute for Safe Medication Practices

and online health service iGuard.org, that will send users e-mail

alerts about drug-name confusion.

And the Food and Drug Administration — which currently rejects more

than a third of proposed names for new drugs because they're too

similar to old ones — is preparing a pilot program that would shift

more responsibility to manufacturers to guard against name confusion.

The goal is to spell out how to better test for potential mix-ups

before companies seek approval to sell their products.

" There are so many new drugs approved each year, this problem can only

get worse, " warns USP vice president Diane Cousins.

At least 1.5 million Americans are estimated to be harmed each year

from a variety of medication errors, and name mix-ups are blamed for a

quarter of them.

Rarely does a company change a drug's name after it hits the market,

although it's happened twice since 2005. The Alzheimer's drug Reminyl

now is named Razadyne, after mix-ups, including two reported deaths,

with the old diabetes drug Amaryl. The cholesterol pill Omacor is now

named Lovaza, after mix-ups with blood-clotting Amicar.

Doctors' notoriously bad handwriting isn't the only culprit. A hurried

pharmacist faced with alphabetized bottles on a shelf might grab the

wrong one.

Nor are computerized prescriptions a panacea. A doctor who

e-prescribes still can click the wrong row on the alphabetized screen,

picking the bone drug Actonel instead of the diabetes drug Actos.

Phone or fax a prescription, and static or smudged ink can turn the

epilepsy drug Lamictal into the antifungal pill Lamisil.

Harder to measure but perhaps more common: A doctor means to prescribe

a new drug but spells out a similar-sounding old one out of habit. Or

the patient misspells or mispronounces one of his drugs, and a health

worker assumes it's the schizophrenia drug Zyprexa, not the

antihistamine Zyrtec.

" We've had cases where a health care professional repeats what they

think the patient's on, and the patient thinks they must know what

they're talking about and agrees, " says USP's Cousins.

Enter the new Web tool. Cousins advises consumers to check it against

their current medications, so they know to pay more attention to

confusing ones at refill time.

Question the pharmacist if the tablets look different than last time —

it might just be a new generic, or it might be the wrong drug

altogether, says pharmacist Marjorie , medication safety

coordinator at MCGHealth, the Medical College of Georgia's health system.

Patients also can ask their doctors to write the diagnosis on the

prescription, a step that pharmacists told the Institute for Safe

Medication Practices would help them prevent errors.

" What they consider most important is knowing why the medication is

used, " says institute president Cohen. " It would go a long way

to interrupt a lot of these mix-ups. "

Write " for heart " next to " clonipine, " for example, and a pharmacist

is less likely to grab similar-sounding gout pills.

But specialists are urging more research on another widely touted

solution: Writing drug names in an eye-catching mix of upper- and

lower-case letters. It sometimes helps but can backfire, warns Dr.

Ruth S. Day, director of Duke University's medical cognition

laboratory. She found users of a heart drug got even more confused

with it was written NIFEdepine — because the change made them

pronounce it " KNIFE-duh-peen " instead of " nie-FEH-duh-peen. "

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