"Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine," she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors. "Anything that takes handwriting out of the equation is a help."
It would also be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine. It's much more difficult to correct a name confusion issue once the products are on the market.
The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins emphasized. "All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'" she said, explaining that this also would help patients avoid confusion if they forget which vial is for which condition.
USP also recommends that "tall man lettering" be implemented in pharmacy software, labeling, and order writing to say, for example, "acetaZOLamide" (glaucoma) and "acetoHEXamide" (diabetes).
Where risk exists, take action to reduce the chance for error. USP recommends the following:
▸ Consider the potential for mix-ups before adding a drug to your formulary.
▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.
▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.
▸ Prohibit verbal orders for soundalikes that have been mixed up at your facility.
Physicians' offices should always require a read-back from pharmacists, making sure "they both say and spell the drug name, especially for these often confusing drug pairs," Ms. Cousins concluded.
The drug with the most mix-ups was cefazolin, which was confused with 15 other drugs, primarily antimicrobials. MS. COUSINS