Drug names being mixed up

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By LAURAN NEERGAARD, AP Medical Writer

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. "