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Practitioners' Reporting NewsSimilar Drug Names Reported to MERIssued February 25, 2004 The following are reports submitted to the USP Medication Errors Reporting (MER) Program regarding similar drug names. The products and descriptions identified in these reports were received between October 1, 2003 and December 31, 2003, where the brand names look alike/sound alike, brand and generic names look alike/sound alike, or generic names look alike/sound alike:
Description: Akineton® (biperiden) 1 mg was ordered with instructions to split a 2 mg tablet. The pharmacy filled the prescription in error with Risperdal (risperidone) 2 mg. The similarity of the generic names was reported as a possible cause of this error. Reporting Practitioner's Actions/Recommendations: Include biperiden vs. risperidone in the next USP similar drug names list.
Description: Cytoxan was given for Cytosar-U. The error was discovered the following day when another bag was being made. The technician pulled the same vial as the previous day. This time, the pharmacist caught the error prior to completion of the 24-hour infusion. Several possible error causes and contributing factors were cited by the reporting practitioner: (1) similar product names, (2) both are used to treat leukemia, (3) both are injectables and are stored in the same cabinet in the pharmacy, (4) the pharmacist was overworked, and (5) no second checks were in place. Reporting Practitioner's Actions/Recommendations: Simplify chemotherapy documentation. A root case analysis was performed.
Description: A patient came in with a prescription for "ES Citalopram." The first pharmacist filled the prescription with citalopram (Celexa™). The prescription then went to a second pharmacist for final checking. The second pharmacist read the original prescription and went to the shelf to look for "extra strength" Celexa. The pharmacist also checked the computer and Drug Facts and Comparisons® for "ES Celexa". Seeing no "ES Celexa," the second pharmacist approved the prescription. No medication was taken and the patient's family member/caregiver returned the medication to the pharmacy. Reporting Practitioner's Actions/Recommendations: When a new drug is named, the name should not sound or look similar to another drug already on the market. Steps identified by the reporting pharmacist that should be taken: (1) familiarize self with all new drugs entering the market (both brand and chemical name), (2) ask sales representatives about any new drugs being approved, (3) read current literature, (4) call the physician for clarification any time there is uncertainty.
Description: The new antibiotic daptomycin (Cubicin™) could be confused with dactinomycin (Cosmegen®). Both are given intravenously as a daily dose, supplied as lyophilized powders, and reconstituted to a pale yellow solution. The reporting pharmacist is concerned that the name similarity will cause a dispensing error. The pharmacist realized the potential for error when discussing daptomycin with a sales representative. The telephone connection was poor and the pharmacist thought the representative was saying "dactomycin." The pharmacist has heard some oncologists incorrectly pronounce dactinomycin as "dactomycin". Reporting Practitioner's Actions/Recommendations: The facility separates chemotherapy agents from all other stock. If daptomycin is added to the hospital formulary, the facility will place "name-alert" warnings in the pharmacy computer system and will place alert stickers on the shelf to help technicians as well.
Description: Depo-Medrol was given intravenously for one dose instead of Solu-Medrol. The wrong vial was sent to the floor. The nurse noticed that the tubing was cloudy, checked the medication cassette, and found Depo-Medrol in the cassette instead of Solu-Medrol. The reporting practitioner cites the following possible error causes: (1) similar brand names, (2) the length of the generic name is long and only "SOL" printed as the brand name on the label, (3) and the generic names are similar. Reporting Practitioner's Actions/Recommendations: The label "For IM use only" should appear in larger or bolder print. The facility put a warning sign at the picking station and is reformatting their labels to include additional information (i.e., the brand name). The facility is also planning to educate their staff regarding this problem.
Description: Solu-Medrol was out of stock in both of the emergency department's automatic dispensing machines. A relatively new technician filled the automatic dispensing machines with Depo-Medrol instead of Solu-Medrol. A nurse pulled what she thought was Solu-Medrol and administered the medication. No adverse reaction occurred and the patient was discharged with no further sequelae. There have been shortages of Solu-Medrol and, at any given time, the facility may or may not have the medication in stock. At the time of this error, Solu-Medrol was in stock, but in short supply. The pharmacist on duty checked the stock supply, but did not catch the error. The reporting pharmacist believes the similarity in the drug names was the cause of the error. Reporting Practitioner's Actions/Recommendations: The facility is planning to do a root cause analysis for all to learn from this incident.
Description: The pharmacist received a question from a physician on the effects of NSAID's on congestive heart failure. Upon further discussion, it was determined that an error was made when taking the patient's medication history. It was thought that the patient was on Indocid, when the patient was actually on Endocet. This was a sound-alike error, which affected the physician's choice of drug therapy for the patient's particular medical problem. Reporting Practitioner's Actions/Recommendations: Healthcare professionals need to be more careful when performing medical histories so that correct medications are documented.
Description: A pharmacist received a call from a nurse in the intensive care unit (ICU) regarding the need for additional ephedrine in order to draw up the dose the physician had ordered. Having read warnings regarding potential errors between ephedrine and epinephrine, the pharmacist questioned the nurse. The nurse stated that she was holding an ampul of ephedrine that was 1 mg/mL and the dose needed was 10 mg. Knowing that ephedrine is available as a 50 mg vial, the pharmacist asked the nurse to verify that she indeed was holding ephedrine. The nurse again confirmed that she was holding ephedrine, had a second person view the ampul, and both agreed that it was ephedrine. The pharmacist then went to the nursing station with an ephedrine 50 mg vial and pointed out that what she was holding was epinephrine 1:1000, or 1 mg/mL, which is different than ephedrine. Prior to this incident, the pharmacy used "Tall Man" lettering to identify both epinephrine and ephedrine in the pharmacy and in the obstetrics automatic dispensing machine, which is the facility's only machine that contains both epinephrine and ephedrine. The facility had not anticipated the potential for staff to try to remove ephedrine from an automatic dispensing machine that did not stock ephedrine. In this case, no ephedrine was stocked in the ICU machine, but the nurse incorrectly selected epinephrine, thinking she was selecting ephedrine. After reviewing this incident, the facility concluded that three causes were the main problems surrounding this error: (1) look-alike/sound-alike names, (2) similar indications, and (3) the need for ephedrine education (i.e., Ephedrine is not a brand name for Epinephrine). Reporting Practitioner's Actions/Recommendations: Since this incident, the facility distributed a hospital-wide summary of the uses of ephedrine and epinephrine. The facility has also added "Tall Man" letting on the automatic dispensing machine computer screens and bins for each drug. In addition, the facility labeled each bin in the machines with a warning that reads, "this is not the same as ePHEDdrine."
Description: The facility is concerned about the potential confusion of Kaletra and Levitra. Dosages and frequency are different, but they sound very similar. Reporting Practitioner's Actions/Recommendations: None provided.
Description: A physician wrote an order for Lexapro. The order as written looked like loxapine. The error was discovered by the ordering physician. After the error was discovered, the order was read by five pharmacists on staff. Each pharmacist interpreted the order as loxapine. The written order was determined to be illegible, although it appeared to be written for the wrong drug. There were no notable adverse effects from the error.
Picture of illegible order
(provided by reporter) Reporting Practitioner's Actions/Recommendations: The facility's policy was revised to ensure that when administering a newly prescribed antipsychotic agent, the order is checked against the patient's consent form, which has the drug name printed, before giving the medication to the patient.
Description: A verbal order was written by a nurse for protamine. The pharmacist interpreted the order as Protonix. When the pharmacist contacted the nurse to inform her that the pharmacy would be sending a piggy-back and that Protonix was not given IV push, the nurse clarified the order as protamine. Reporting Practitioner's Actions/Recommendations: The reporting practitioner believes prescriber order entry may have prevented this error from occurring and that indications should be included as part of all orders.
Description: A physician prescribed Zostrix cream with directions to "apply to affected area QID." There were no other instructions. Under the order, the physician wrote, "D/C Zoster precautions." The pharmacist, who entered the order, saw the "D/C Zoster precautions" and mistakenly entered Zovirax in the pharmacy computer. The Zovirax cream was dispensed and the error not caught by the nurse. The next day, the physician saw the tube of Zovirax cream in the patient's room. The error was then perpetuated after the pharmacy corrected the order entry error. The pharmacy sent the correct Zostrix cream to the floor, but the incorrect Zovirax cream was not returned. The physician found both creams in the patient's room the following day, and the nurse was applying the incorrect Zovirax cream. The reporting pharmacist cites the following possible error causes: (1) both products start with the letter "Z" and end with the letter "X," (2) both are topical creams and are used to treat conditions related to herpes. Reporting Practitioner's Actions/Recommendations: The reporting pharmacist believes that using the generic name (capsaicin vs. acyclovir) would have helped in this instance. The indication written on the medication order may have also helped (post-herpetic neuralgia vs. genital herpes). Pharmacies need to have a process so that discontinued medications are retrieved. Nurses need to be familiar with the indications for the use of the products they are applying. A root cause analysis was conducted and the following steps will be taken: (1) an alert will be put in the pharmacy computer system to prompt the pharmacist to select the correct ointment during computer order entry, (2) education efforts regarding the confusion between these two medications will be communicated with the medical staff, as well as the appropriate indications for use of each of these medications, (3) the prescribing staff will be encouraged to use the generic names of these medications when ordering these particular medications, (4) a process of retrieving incorrectly dispensed medications will be developed between the pharmacy and nursing, and (5) the practice of keeping topical medications at the bedside will be reviewed. Practitioners are encouraged to report medication errors to the USP MER Program at www.usp.org/patientSafety/mer/. Reporting forms can also be printed at that address or requested by calling 1-800-23-ERROR (1-800-233-7767). 
Readers are advised that official USP cautions and warnings for drugs appear in the USP–NF or USP DI. Unless otherwise indicated, any advice or opinions expressed herein reflect solely the judgment of USP staff. Such statements are intended for further consideration and evaluation and may or may not be applicable to a particular practice. The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices. |
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