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Study Finds Drug Name Mix-Ups Common

Top 10 drugs all make the mix-up list

January 31, 2008

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The rate of drug name mix-ups has more than doubled since 2004, according to a new report from the US Pharmacopeia.

The group, which regulates the generic names of drugs and advises pharmaceutical companies, reviewed more than 26,000 records and identified 1,470 unique drugs involved in errors due to similar brand or generic names.

"Together, these drug names contributed to more than 3,170 pairs — nearly double the 1,750 product pairs appearing on USP's 2004 list," the organization said in a statement.

"According to this report's findings, 1.4% of the errors resulted in patient harm, including seven that may have caused or contributed to patient deaths."

The top 10 drugs sold in the US in 2006 all made the mix-up list, including cholesterol drug Lipitor, heart drugs Toprol and Norvasc, antidepressant Lexapro, stomach acid pill Nexium and asthma drug Singulair. The USP researchers said 519 facilities reported on 176,409 errors in 2006.

"The percentage of harmful errors has remained above 1% for more than seven years," they said.

Some errors could be easily remedied if pharmacies separated or otherwise differentiated easily confused drugs, said USP patient safety expert Diane Cousins.

Prescriptions should include simple words such as "for sinus", "for heart", "for high blood pressure", Cousins added.

At the press conference held in Washington, D.C. this week, the association presented testimony from a critical care physician who once worked at Johns Hopkins University in Baltimore.

Dr Julius Pham claimed he saw a critically ill heart patient getting an antibiotic instead of a drug to support his blood pressure — the kind of mix-up that is increasingly common in the United States, according to the report.

"If you have ever had that sinking feeling that drops to the bottom of your stomach, I had it," Pham told reporters. "Unfortunately, the patient did not do well."

What went wrong?

"A nurse had confused Levophed, which can boost blood pressure, with the antibiotic Levaquin," answered Pham.

The United States Pharmacopeia (USP) is the official public standards-setting authority for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the United States. USP sets standards for the quality of these products and works with healthcare providers to help them reach the standards. USP's standards are also recognized and used in more than 130 countries.

The full report is available online.

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