USP Asks for Help in Heading Off Drug Errors

“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 said. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said.

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. To build awareness, USP recommends disseminating information about products that have been confused at your facility, and prohibiting verbal orders for soundalikes.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins said.

Some errors result from physicians' use of the same abbreviation for two drugs: clon for clonazepam and clonapine. MS. COUSINS