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U.S. Pharmacopeia 8th Annual MEDMARX(R) Report Indicates Look-Alike/Sound-Alike Drugs Lead to Thousands of Medication Errors Nationwide

Each of the top 10 most prescribed drugs in America commonly confused with

at least one other drug

ROCKVILLE, Md., Jan. 29 /PRNewswire/ -- The 8th annual national MEDMARX(R) Data Report released today by the U.S. Pharmacopeia (USP) revealed that more than 1,400 commonly used drugs are involved in errors linked to drug names that look alike or sound alike. According to findings in the MEDMARX report, 1.4% of the errors resulted in patient harm, including seven errors that may have caused or contributed to patient deaths. However, due to widespread underreporting of incidents, the study's authors believe that the number of adverse events resulting from look-alike/sound-alike errors is actually understated.

For this year's report, USP reviewed more than 26,000 records submitted to the MEDMARX database from 2003 to 2006. These records revealed that 1,470 different drugs are implicated in medication errors due to brand and/or generic names that looked or sounded alike. From this data, USP compiled a list of 3,170 pairs of names that look and/or sound alike. This result is nearly double the 1,750 pairs that were identified in USP's previous report on this topic in 2004.

In response to the findings, USP is calling on prescribers and pharmacists to include an "indication for use" on prescriptions. Indication for use is a phrase that signals why the patient is taking the drug (e.g. cough, infection, rash). To prevent medication errors, USP recommends that this powerful piece of information be conveyed at several points along the health care continuum. Additionally, prescribers should use trustworthy decision-support tools to help ensure accuracy. Tools such as Epocrates, Lexi-Drugs, and others have been helpful in reducing potential medication errors, and the addition of MEDMARX look-alike/sound-alike data will make such tools even stronger.

"Errors resulting from look-alike/sound-alike drugs are a problem that spans the entire health care system," said Darrell Abernethy, M.D., Ph.D., chief science officer, USP. "By recording and communicating not only the name of the drug, but also what it is being used for, prescribers, pharmacists and consumers can work together to dramatically reduce these types of medication errors."

Consumers picking up prescriptions should check the indication for use appearing on the drug's label or ask their pharmacist for this information. If the indication given by the pharmacy is different from what the prescriber said the medication is for, that is a red flag for the consumer to ask questions. Consumers should also exercise their right to receive counseling from the pharmacist every time they begin a new medication to ensure they know the name of the drug and its pronunciation, what it is and how to take it.

"This report brings a new dimension to USP's list of look-alike and/or sound-alike drug names by providing additional evidence about the many ways in which easily confused names can lead directly to medication errors," said Diane Cousins, R. Ph., USP's vice president of healthcare quality and information and co-author of the MEDMARX report.

"The nation will now be able to access the most comprehensive list of similar names that is based on actual reports of errors, and, for the first time, a list that further delineates the error's effect on patient outcomes."

The MEDMARX Data Report A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine's Call for Action analyzed records from 2003 to 2006 involving medication errors due to drug names that look or sound similar. The report includes the largest known list of look-alike/sound-alike drugs and is the only list based on reported medication errors.

USP's MEDMARX is an anonymous, Internet-accessible program used by hospitals and related institutions nationwide to report, track, and analyze medication errors. Since its inception in 1998, MEDMARX has received more than 1.2 million reports of medication errors from more than 870 health care facilities across the U.S. MEDMARX is the largest nongovernmental, Internet- accessible database of medication errors in the U.S. USP also operates, in conjunction with the Institute for Safe Medication Practices, a Medication Errors Reporting Program (MER). Data from MER, which allows health care professionals to report potential and actual medication errors directly to USP on a confidential and anonymous basis, were also used in compiling the MEDMARX report. USP recently announced a strategic alliance with Quantros(TM), providers of hospital applications. Under this arrangement, the MEDMARX database will grow even larger and more robust with the addition of Quantros' extensive patient-safety events database.

USP-Advancing Public Health Since 1820

The United States Pharmacopeia (USP) is a private, non-profit, standards-setting organization that advances public health by ensuring the quality and consistency of medicines, promoting the safe and proper use of medications, and verifying ingredients in dietary supplements. These standards, which are recognized worldwide, are developed by a unique process of public involvement through the contributions of volunteers representing pharmacy, medicine, and other health care professions, as well as science, academia, government, the pharmaceutical industry, and consumer organizations. For more information about USP and its four public health programs, visit

SOURCE U.S. Pharmacopeia
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