ISMP Medication Error Cases and Prevention Checklist

In a prior post from this week concerning pharmacy error injury, our Maryland Medication Error Attorneys at Lebowitz & Mzhen, LLC discussed a recent study published by the Institute of Medication Practices (ISMP), and the ongoing problem with drug naming standards in extended release medications.

In this study, the ISMP revealed a series of cases reported to the institute, in which drug name suffix medication mistakes have frequently occurred. This study showed specific case examples in order to establish clearer naming conventions in the industry, and improve comprehensive pharmacist and patient awareness—to prevent pharmacy error injury and misfills in the future.

The ISMP study reported these specific medication mistake cases:

• Physicians often prescribe extended release products without the correct suffix, or with a suffix that does not exist for that particular product.

• In an analysis of 402 prescribing errors published by Medscape Pharmacists, the most common type of error in the study (280 cases, 69.7%) was failure to specify the controlled release formulation.

• The ISMP received reports of cases in which pharmacists dispensed Metadate ER instead of Metadate CD—two different extended release forms of methylphenidate-UCB, a stimulant medicine commonly used to treat ADHD. In one case, a prescription for Metadate CD 20 mg was misfiled at a pharmacy, where the staff dispensed Metadate ER 20 mg.

• Some products have multiple suffixes for different formulations of the same drug. Diltiazem products for example (calcium channel blockers) are used to slow the heart rate and normalize the heart rhythm in hypertension and arrhythmia. The many suffixes for Diltiazem include SR, CD, XR, XT, and LA.

• Electronic prescribing can also lead to medication errors on behalf of the prescriber. In one case, a prescriber electronically selected metroprolol tartrate instead of metoprolol succinate because of choosing incorrectly on his PDA.

According to this report, pharmacists, practitioners, and patients should take extra care when reviewing the different formulations and medication names, especially if the medication is available in more than one dosage form.

The ISMP recommends the following medication error prevention checklist:

• Practitioners should always state “extended release” or “sustained release” instead of abbreviations when giving verbal orders.

• Patient history should always be reviewed for possible discrepancies, when ordering new prescriptions with the pharmacist electronically.

• Pharmacists should build alerts into computer systems and warn pharmacy staff about the drug differences by clearly labeling drug containers.

• Pharmacy staff should create mnemonics, acronyms or passwords to individualize formulations in the computer system for prescription ordering.

• Drugs with similar names should be stored in separate locations, with clear labels identifying medication differences in the pharmacy.

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), also recommends that prescribers always indicate the complete drug name, including the suffix when ordering medications, and that pharmacists call to clarify that the suffix on a prescription title matches the prescribed dosing schedule. They recommend that practitioners be proactive, and examine drugs with suffixes in the title to eliminate error.

The NCC MERP encourages the USP, FDA and pharmaceutical industry to come together to standardize the use of drug-name suffixes, in order to create a future state where drug names suffixes are readily recognized and understood by prescribers and consumers—avoiding medication mistakes and injury.

Our Maryland Medication Mistake Attorneys are committed to making sure that medication error victims and their loved ones receive the personal injury compensation they deserve. Contact Lebowitz & Mzhen, LLC today for a free consultation.

The Alphabet Soup of Drug Names Suffixes, ISMP Error Alert—Pharmacy Today, August 2009

Related Web Resources:

Institute for Safe Medication Practices, (ISMP)

Council Recommendations: Promoting the Safe Use of Suffixes in Prescription Drug Names, National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

MedWatch: The FDA Safety Information and Adverse Event Reporting Program

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