What’s in a name? According to William Shakespeare, not much: “That which we call a rose by any other name would smell as sweet.” In this famous line, Juliet complains that it is Romeo’s name that keeps them apart because of a family feud.
In the world of pharmaceuticals, the wrong name can make the difference between life and death. That’s because look-alike and sound-alike drugs are frequently confused.
The U.S. Pharmacopeia (USP) has just issued a report documenting that drug name mix-ups are rising at an alarming rate. USP is an organization that sets standards for drugs and dietary supplements. It runs a clearing-house for hospitals to report medication errors anonymously.
The USP report says that there are more than 3,000 pairs of look-alike or sound-alike drugs that could lead to serious problems. Here are just a few examples:
- Celebrex (for arthritis) vs. Celexa (an antidepressant)
- Ferro-Sequel (an iron supplement) vs. Seroquel (an antipsychotic)
- Fosamax (for osteoporosis) vs. Topamax (for epilepsy)
- Lamictal (for epilepsy) vs. Lamisil (for fungal infections)
- Zestril (for high blood pressure) vs. Zetia (for cholesterol) vs. Zyrtec (for allergies) vs. Zyprexa (for schizophrenia)
Imagine yourself behind the counter of a busy pharmacy. The phone is ringing nonstop and messages are being left on voice mail. Some prescriptions are coming in on the fax machine and impatient customers are queued up at the counter waiting for their prescriptions.
Amidst the hustle and bustle, it is not surprising that drug names get mixed up. Someone could easily end up with Zantac instead of Xanax or Topamax instead of Fosamax.
How often are mistakes made? One survey reported that 2 percent of all prescriptions are dispensed incorrectly. That may seem trivial, but when you consider that billions of pill bottles are sold each year that totals over 50 million mistakes annually (Journal of the American Pharmaceutical Association, March-April, 2003). Many are trivial, but some can be life threatening.
Several years ago we heard from a woman whose mother died because of a pharmacy mix-up. The woman was dispensed an estrogen hormone instead of the blood thinner warfarin (Coumadin).
To avoid being a victim of a mistake, here are some People’s Pharmacy tips:
- Never have your prescription phoned in. There is too much opportunity for sound-alike drugs to be confused over the phone.
- Make sure your prescription is printed or typed in English. Do not accept Latin code or illegible scrawl.
- Do not allow your prescription to be faxed. The loss of quality in transmission might foster confusion.
- Keep a photocopy of your prescription so you can verify that what you get at the pharmacy is what your doctor ordered.
- Double-check the label and the pills before you leave the pharmacy counter. If you count the bills a bank teller hands you, you should be even more careful with your medicine.
- If you have any suspicions that a mistake has been made, do not hesitate to speak with the pharmacist.
A rose by any name would smell as sweet. A drug by the wrong name, on the other hand, could be lethal.
