Patient Safety Alert: ISMP Reports Medication Error with Drug Name Suffixes

As Maryland Medication Error Attorneys, we have been following a recent study published by the Institute of Safe Medication Practices (ISMP), about the lack of prescription drug naming standards in extended release medications that lead to pharmacy error injury.

According to the study, although extended release drug formulations provide multiple benefits for many patients, the titles used for many medications are often confusing, and can cause patient error when the same drug is presented with several different oral dosage forms in the suffix.

Extended release drug formulations play an important role in maintaining consistent prescription therapies, by preventing the need for patients to remember to repeat dosages—delivering a steady dose of the medication throughout a specific period of time. The difficulty with many of these medications comes in the name. According to the study, drug manufacturers add suffixes or modifiers to already well-known medication names, to keep awareness of the brand, yet differentiate between the immediate-release counterparts. For example: Wellbutrin SR is a sustained release anti-depressant, whereas Wellbutrin XL is the extended-release version. Same name, different release rate.

ISMP reported that there is currently no standardization for the many different types of extended release formulations, nor is there any standard definition describing the dosage or release characteristics of the drugs. Patients are left to discern between identical formulations with different suffixes, or even similar prescription suffixes with dissimilar formulations, creating potential for pharmacy error injury or misfills.

The ISMP has recommended to the United States Pharmacopeial Convention (USP) that naming standards be established to avoid patient confusion with the many similar formulations of the same drug, by incorporating suffixes or descriptive phrases into the drug names, or by inventing new brand names to designate different formulation properties. The FDA is also reportedly aware of the suffix problems and currently exploring new ideas to improve the naming convention.

If you or someone you know has experienced pharmacy error injury in Maryland or Washington, D.C., contact the attorneys at Lebowitz and Mzhen, LLC 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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