DRUG NAMES INCORPORATING ABBREVIATIONS SHOULD BE AVOIDED TO PREVENT MEDICATION ERRORS, INSTITUTE OFFICIAL TELLS FDA; DOCTORS CONFUSE SUFFIXES
Abbreviations or initials should not be used for drug names so that medication errors can be prevented, Institute for Safe Medication Practices President and founder Michael Cohen suggested to a Nov. 18 Center for Drug Evaluation and Research seminar. Maintaining that many fatal medication errors are avoidable, Cohen said that drug name mixups by hospital personnel would be reduced if companies would not identify their products by abbreviations. He showed a slide of a prescription on which a physician ordered "AZT" for a bone marrow transplant patient who needed azothioprine, an immunosuppressive -- not the anti-AIDS treatment Retrovir (Burroughs Wellcome's zidovudine) which boosts immune response and is commonly referred to as "AZT." Cohen's institute persuaded Lederle to change an ad for methotrexate that used the abbreviation MTX to avoid confusion with mitoxantrone. The institute recommends "that no drug names be abbreviated;" he asked FDA reviewers to inform companies that "it's time to stop using abbreviations for these drug names." Abbreviated suffixes also are causing a "big problem," Cohen declared. The recent trend toward suffixes to indicate a new dosage form of a recognized brand is exemplified by such products as Procardia XL, Catapres TTS, Cardizem CD and Robitussin AC. One published study found that "19 errors" with such suffixes were reported in calendar 1987, but between 1991 and 1992 the study found 119 errors involving suffixes to drug names, Cohen reported. "Doctors leave them off" prescriptions, or the suffixes are misread, he explained. ISMP argues that such suffixes should be either standardized or eliminated. * Cohen founded ISMP in 1975 and works closely with Temple University pharmacy professor Neil Davis. Cohen said several professional journals and association newsletters carry notices and information from the institute, which gathers reports of medication errors from a variety of sources. ISMP also works with FDA, the Pharmaceutical Manufacturers Association, the American Medical Association, the American Pharmaceutical Association, the American Society of Hospital Pharmacists, the U.S. Pharmacopeia, U.S. Adopted Names and other organizations. Vincristine and vinblastine have names that are structurally and phonetically similar, Cohen said. "That's been a long-standing problem; through the years, we've had several errors that have been reported," he said. "Vincristine usually winds up getting given at the vinblastine dose, which is much higher, and the toxicity is frequently irreversible," he said. "Since vincristine will still be here years from now [and] it's an excellent agent against leukemia and other types of tumors...consideration ought to be given to a name change," Cohen said. ISMP's recommendations generally are "starting to have more impact now than...in the past," he noted. FDA should induce companies to make special labeling and packaging considerations based on the potential for drug misuse after approval, Cohen suggested. "There are definitely some medications which you know are going to be a lot more dangerous than other medications, if misused," Cohen pointed out. FDA should "keep that in mind as the drug goes through the approval process or even after the drug is marketed" and the agency considers labeling and packaging design. Cohen suggested that FDA and industry can train physicians to include indications and dosage strengths on prescription forms through drug company advertising. Ads that picture sample prescriptions should include such information with the drug name to help confirm the identity of prescribed drugs. Another potential solution may be found in barcoding. Cohen said including bar codes on labels could "prevent an awful lot of injuries and errors." * Drugs "repeatedly" involved in "medication errors and that result in injuries and death" include aminophylline and theophylline, chemotherapies, heparin, insulin, lidocaine, neuromuscular blockers, parenteral narcotics, vasopressors and electrolyte concentrates, Cohen said.
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