USP Quality Review

No. 68, Issued September 1999

Confusion Creates Errors

Practitioners' fears that these similar names would potentially cause medication errors have unfortunately been realized. More than two-thirds of the submissions received by the USP MER Program report that an actual error occurred. Of these reports, nearly 50% of the errors reached the patient. Two of the reported actual errors were described as involving patient harm. It should be noted, however, that the true incidence of errors resulting from the confusion between these products and the outcomes thereof is not known because of the spontaneous nature of the USP MER Program. Case studies (see Figure 1) abstracted from actual MER Program reports illustrate the potential and actual hazards that may occur from misinterpreting the similar proprietary names of these products.