A prospective study of medication errors arising out of look-alike and sound-alike brand names confusion

Abstract

Objective: The study was conducted to estimate and to analyze the medications errors because of look-alike & sound-alike brand names confusion and prepare the list of such brand names and further to suggest methods to reduce errors arising out of such confusion.

Materials and methods: The study was conducted in a general hospital in Delhi over a period of six months. The possibilities of errors because of brand name confusion was high when the staff nurses were sending drug orders to the pharmacy because these drug orders were send electronically. In the used software the brand names of drugs were displayed alphabetically and the nurse had to select the drug by clicking on it. After making the list of prescribed drugs, it is sent to the pharmacy for dispensing. The errors in the drug ordering method were assessed for six months and a list of commonly involved brand names was made which was further classified into different categories (Category 1 – Look alike drugs with same generic name, Category 2 – Look alike drugs with different generic name, Category 3 – Sound alike drugs with same generic name, Category 4 – Sound alike drugs with different generic name, Category 5 – Identical brand names with same generic name) and analyzed for seriousness on the basis of there potential to cause patient harm.

Results: The occurrence of these 5 different categories in percentages was: Category 1 – 4.51%, Category 2 – 4.92%, Category 3 – 0%, Category 4 – 6.56% and Category 5 – 84.01%. Category 5 errors were most commonly seen. Further, the monthly trend for category 5 errors showed a decreasing number of errors and improvement in quality of drug order entry.

Conclusion: Most commonly brand name confusion is seen with almost identical brand names for combination drugs. Such type of errors could be dangerous (e.g., in antihypertensive or hypoglycemic drug combinations). They also increase the cost of therapy and unnecessary exposure of the patient to more drugs and there side effects. Brand name confusion could be prevented by strict adherence to the hospital drug formulary. It would be a good practice to write the generic name of the prescribed drug in brackets along with the brand name. This matter requires some serious legal steps to stop the marketing of those brand names with intentional look alike and sound alike names.