Generic Drug Name Confusion Continues to Cause Problems for U.S. Consumers, ISMP Reports

According to a new study by drug safety experts, confusion over generic drug names, which are often long and include out-of-the-ordinary sound combinations, continue to cause reports of medication mistakes and errors among U.S. consumers. 

The Institute for Safe Medication Practices (ISMP) released a report last week, which found one out of every 1,0000 medication orders or prescriptions have been associated with selecting the wrong drug during the prescribing, transcribing, dispensing or administering processes.

While there has been an overall decrease in name confusion regarding brand name drugs in recent years, the report indicates that generic drug names are actually causing more confusion over the same time period.

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Drug name confusion can lead to a patient  being prescribed the wrong drug based on its name similarity to the drug the patient was supposed to received. This often happens at the doctor’s office or at the pharmacy. However, the report indicates that generic confusion is also occurring with medication orders in hospitals.

The ISMP report highlighted national efforts since 2004 to reduce the number of drug confusion problems. The researchers conducted a retrospective analysis of name-related medication errors voluntarily reported to the ISMP National Medication Errors Reporting Program between 2012–2016. They compared that information to data reported between 2000–2004.

The findings indicate that there were 816 reports of drug name confusion between 2000 and 2004, 507 of which involved brand-name drugs being confused with other brand name drugs. Another 91 of those incidents involved brand name drugs confused with generic drug names, and 218 involved confusion between two generic drug names. However, from 2012 to 2016, there were only 603 reports of drug name confusion overall.

Confusion between different brand-name drugs fell to 183 reports, and there were only 51 reports involving confusion between brand name drugs and generic drugs. But confusion between different generic drug names increased to 369 reports.

The study indicates that the decreases in brand-name drug confusion was likely linked to efforts by manufacturers and the FDA to test brand names prior to approval.

The data appears to indicate that the trend is toward confusion of generic drugs for other generic drugs.

There are more than 27,000 drugs on the U.S. market, leading to many opportunities for confusion. One in every 1,000 medication orders in a hospital and one in every 1,000 prescriptions in a pharmacy are associated with drug name confusion.

Spelling, similarities in length, syllables, and sound are all factors that contribute to the confusion.

For example, one report involved a patient prescribed morphine, which is a powerful painkiller. Yet, the patient was given hydromorphone instead, which is five times stronger than morphine. This resulted in a fatal overdose.

Similarly, confusion can occur between the drug sulfadiazine, an antibiotic, and the drug sulfasalazine, which is used to treat ulcerative colitis and rheumatoid arthritis. Reports concerning confusion of clobazam for clonazepam were also made.

Drug name mistakes are likely to increase as the U.S. market share of generic medications continues to rise, the researchers warned.

The ISMP is suggesting new standards of evaluating generic names before approval. The group also calls for a name change provision for new drug names that face confusion problems after approved.


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