Sometimes you recognize your mistake
right away.
But sometimes it only dawns on
you gradually. That was the case for Dr Ben Chan, now
the CEO of Ontario's Health Quality Council.
"I remember doing a locum years
ago and I had a patient come in and say they heard about
this medication, E-Vista, and we were chatting about
it," he says. But something didn't add up. "We were
talking about different medications," he realized. He
looked it up and, lo and behold, it while he was talking
about E-Vista, his patient was asking about Evista.
The former was a trade name for hydroxyzine, an antihistamine.
The latter is the name for raloxifene, a selective estrogen
receptor modulator, an osteoporosis drug. "I was shocked,"
Dr Chan recalls.
The "E-Vista" name is no longer
in use, but the problem of look-alike or sound-alike
(LA/SA in pharmacovigilance parlance) drug names remains:
as many as 25% of medication errors are caused by such
mix-ups.
CONFUSION
REIGNS
"The problem with look-alike, sound-alike drugs is more
common than we realize," says Dr Chan. A recent study
by the United States Pharmacopeia, a nonprofit medication
safety thinktank, identified 3,170 pairs of drug names
that look or sound dangerously alike. Between 1% and
2% of drug name mix-ups result in harm or in death.
The situation in Canada is no different,
says David U, the president of the nonprofit Institute
of Safe Medication Practices Canada. "We still have
a ways to go," he says.
PLAIN
AND CLEAR
In 2005, Health Canada released a "Guidance for Industry"
document that suggested (voluntary) drug naming practices
designed to avert LA/SA errors. Unfortunately, the government's
LA/SA strategy hasn't been as effective as hoped so
far. "The Department experienced delays in the implementation
phase of the initiative," a Health Canada spokesperson
told NRM.
Two other government projects already
in the works are set to finally come to fruition soon.
One, an artificial-intelligence computer program to
automate LA/SA name comparisons, is expected to be launched
in the next few months. The other, the Canadian Medication
Incident Reporting and Prevention System, is a voluntary
reporting program that will monitor all kinds of adverse
events from drugs, including those caused by LA/SA confusion.
National pilot testing is supposed to be finished by
the end of March 2009.
Esoteric government programs aside,
physicians can reduce LA/SA confusion in several ways.
Here are a few:
- "medication reconciliation"
— a highfalutin way of saying "Check your patients'
prescriptions carefully at admission and discharge"
- write your scripts more clearly
— try writing all in capitals
- don't abbreviate — spell
out full names of drugs or write down both the trade
and generic names
- write down the indication of
drug as well (patient confidentiality concerns are
unfounded, says Mr U);
- use an EMR system that can flag
possible mix-ups
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