Correspondence

More on Drug-Name Confusion

N Engl J Med 1995; 332:754-755March 16, 1995

Article

To the Editor:

Burroughs Wellcome shares the concern expressed by Pourmotabbed (Oct. 27 issue)1 about confusion between our Lanoxin brand of digoxin and another manufacturer's Levoxine brand of levothyroxine sodium. The medication error described underscores an important patient-safety issue.

Last July, our company mailed all pharmacists a notice informing them of reports of confusion between the Lanoxin and Levoxine brand names. We also asked the company that manufactures Levoxine to change its brand name to avoid situations such as the one Pourmotabbed describes. Lanoxin is a long-established brand name that pharmacists and physicians know. It is also the senior brand name of the two. Recently, the company that makes Levoxine informed us that it is changing the brand name of its levothyroxine product.

We believe that careful selection of brand names by pharmaceutical companies, the use of clearly written or printed prescriptions or computer-printed prescriptions, and the continued alertness of those reading prescriptions will minimize prescribing errors in the future and preserve patient safety.

Judith M. Kramer, M.D.
Burroughs Wellcome, Research Triangle Park, NC 27709-2700

1 References

1
Pourmotabbed G. The naming of drugs is a difficult matter. N Engl J Med 1994;331:1163-1163
Full Text | Web of Science | Medline

To the Editor:

The medication error reported by Dr. Pourmotabbed was not surprising. The responsibility for the avoidance of such errors rests with all health care professionals. In many practice settings, pharmacists actively promote programs to avoid medication errors. Prescribers can decrease the likelihood of such errors by doing the following1: writing legibly, or printing or typing prescriptions; including the diagnosis or indication; writing out the name of a medication, rather than abbreviating it; indicating the generic name of the drug, as well as the brand name, if necessary; specifically and clearly noting all instructions to patients; abandoning the use of “as directed” in instructions to patients; using a zero before a decimal point (0.5 mg, not .5 mg) but not after one (5 mg, not 5.0 mg); spelling out the word “units”; and always using the metric system.

Many products on the market have names that look or sound similar. Pharmaceutical manufacturers have a responsibility to choose the brand names of new products carefully to avoid confusion. Efforts to prevent medication errors will be most successful with a team approach.

Miriam L. Levinson, Pharm.D.
Deborah R. Saine, R.Ph.
Meriter Hospital, Madison, WI 53715

1 References

1
American Society of Hospital Pharmacists. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm 1993;50:305-314
Medline

To the Editor:

I doubt that any licensed pharmacist asked to fill a prescription for “Levoxine at a dose of 0.125 mg daily for thyroid hormone replacement” would have incorrectly substituted Lanoxin at a dose of 0.125 mg. Writing the indication for the drug on the prescription not only serves as a safety measure, but also allows the pharmacist to counsel the patient appropriately on the medication, as now required by federal law for Medicaid recipients and encouraged by the pharmacy profession for all patients. Most medications have more than one indication, which can make counseling very difficult if the reason for the use of a drug is not recorded on the prescription, especially when the patient is unsure why he or she is receiving the drug.

At our institution, a “for” prompt is now included on prescription forms to encourage physicians to record the indication for the medication. This information will then appear on the label of the filled prescription, thus letting the patient know why the medication was prescribed and letting the pharmacist know how to educate the patient appropriately.

Karen Franklin, Pharm.D.
Veterans Affairs Medical Center, Nashville, TN 37212-2637

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