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New efforts under way to prevent medication mixups

Clonidine Klonopin Colchicine



Celexa Celebrex











Take the generic drug clonidine for high blood pressure? Double-check that you didn't leave the drugstore with Klonopin for seizures, or the gout medicine colchicine.

Mixing up drug names because they look or sound alike is among the most common types of medical mistakes, and it can be deadly. Now new efforts are aiming to stem the confusion.

Nearly 1,500 commonly used drugs have names so similar to at least one other medication that they've already caused mixups, says a major study by the U.S. Pharmacopeia, which helps set drug standards and promotes safety.

Last month the influential group opened a Web-based tool to let consumers and doctors easily check if they're using or prescribing any of these error-prone drugs, and what they might confuse it with. Take a look at the drug error finder at and it's easy to see how mistakes can happen.

Another project, a patient-oriented Web site that will send users e-mail alerts about drug name confusion, is in the works. It's a partnership of the nonprofit Institute for Safe Medication Practices and online health service

The Food and Drug Administration, which rejects more than a third of proposed names for new drugs because they're too similar to old ones, is preparing a program to shift more responsibility to manufacturers. The goal is to spell out how to better test for potential mixups before companies seek approval to sell their products.

"There are so many new drugs approved each year, this problem can only get worse," says USP vice president Diane Cousins.

At least 1.5-million Americans are estimated to be harmed each year from medication errors, and name mixups are blamed for a quarter of them.

Rarely does a company change a drug's name after it hits the market, although it has happened twice since 2005. The Alzheimer's drug Reminyl now is named Razadyne, after mixups with the old diabetes drug Amaryl. The cholesterol pill Omacor is now named Lovaza, after mixups with blood-clotting Amicar.

Doctors' notoriously bad handwriting isn't the only culprit. A hurried pharmacist faced with alphabetized bottles on a shelf might grab the wrong one. Phone or fax a prescription, and static or smudged ink can turn epilepsy drug Lamictal into antifungal pill Lamisil.

A good way to make sure you get the right medication is to know exactly what the medication is for, says institute president Michael Cohen. "It would go a long way to interrupt a lot of these mixups."














>>fast facts

Minimizing mistakes

• Ask your doctor what drug is being prescribed, at what dose, and ask for written instructions for use.

• Ask your doctor to write a short description of the diagnosis directly on the prescription — "for heart" or "for allergies" — right next to the drug name.

Check the label on the drug bottle before leaving the pharmacy, to ensure the name is what your doctor told you. If it's a refill, open the bottle to make sure the pills are the same color, shape, size and dosage as the original prescription.

Sources: U.S. Pharmacopeia, Institute for Safe Medication Practices

New efforts under way to prevent medication mixups 09/22/08 [Last modified: Wednesday, November 3, 2010 1:05pm]
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