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USP announces new tool to help prevent medication mix-ups due to look alike/sound alike drug names

Rockville, Md., August 25, 2008 The U.S. Pharmacopeial (USP) Convention today announces a new drug safety tool designed to help patients, caregivers, pharmacists, physicians and others in avoiding medication errors that may occur because of drug names that look alike and/or sound alike. This "Drug Error Finder" is a searchable database of almost 1,500 commonly used drugs reported to be involved in medication mix-ups in the U.S. health care system since 2003. The database is publicly available at no cost on USP's Web site at

The Drug Error Finder is derived from a list of 1,470 unique drugs that were implicated in medication errors due to brand and/or generic drug names that look or sound alike and reported to USP's MEDMARXan anonymous database used by hospitals and health care systems across the United States to report, track and analyze medication errorsor to USP's Medication Errors Reporting Program. The list was included in USP's 8th annual MEDMARX Data Report, released in January 2008, which examined more than 26,000 error records related to similar drug names submitted to the database from 2003 to 2006. This is the largest known list of look alike, sound alike drug names in the world based on actual medication error reports.

"As more medications are approved for market each year and become available to Americans, the opportunity for potentially dangerous or even deadly errors due to drug mix-ups from look alike or sound alike names becomes increasingly high," said Diane Cousins, R.Ph., USP vice president of healthcare quality and information. "While one drug name may be nearly identical to that of another drug, the two could be used for completely different conditions. This presents a major public health threat, and we think this new tool can play an important role in helping to reduce patient risk associated with this problem."

One example of a drug involved in such errors reported to MEDMARX is Clonidine, a high blood pressure medication. In actual instances reported to USP, this drug was confused with multiple drugs, including Colchicine (used for gout), Cetirizine (an antihistamine), and Clonazepam and its brand name, Klonopin (used for anxiety and seizures). "As one can imagine, for someone with hypertension, receiving the wrong medication could present a potentially severe consequence," noted Cousins. "This is exactly the type of mix-up we think could be avoided through tools such as our Drug Error Finder. This may be useful to parties across the health care system who are involved in dispensing and administering medicationsand especially to caregivers and to patients, who should always remain vigilant and participate actively in their care." The 2008 MEDMARX Report found 25 different levels of individuals involved in similar name errors, from pharmacy technicians, nurses and physicians to patients and family members.

To use the Drug Error Finder, simply type in the name of the particular drug of interest. In addition to rapidly generating a list of medications that have been confused with that drug, the tool will also allow users to see the severity attributed to the reported errors involving the drug (ranging from Category A for "potential for error" to Category I for "death").

The Drug Error Finder is one component of USP's response to the Institute of Medicine's 2006 report, Preventing Medication Errors, which calls on the government and public health organizations to address medication errors resulting from similar labeling and packaging as well as confusingly similar drug names.


Contact: Sandra Kim
US Pharmacopeia

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