Enseñar a escribir: ¿Cuál es el método? * JULIO AGUSTÍN VARELA BARRAZA,1 GONZALO NAVA BUSTOS,1BAUDELIO LARA GARCÍA,2 ROGELIO ZAMBRANO GUZMÁN3Aunque existen diversos métodos para enseñar a leer, para la escritura no existe un método, excepto el queestá dirigido al dibujo de trazos y letras. Se describe el papel que tiene el instrumento para escribir y su impor-tancia en la forma en
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Jkmc vol 2 no 2 iss4 cs55 book.indbJournal of Kathmandu Medical College, Vol. 2, No. 2, Issue 4, Apr.-Jun., 2013 Sanjaya Mani Dixit, Lecturer, Department of Pharmacology, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal Abstract
Background: ALMEX and ALMOX; ASOM and AZOM; TRIAD, TRIAD P and TRIAD PF; folic acid and folinic acid; Vincristine
and Vinblastine. Such look-alike and sound-alike medicines because of the similarity in their names create confusion
while dispensing and administration/consumption of medicine. This may eventually cause varied degree of harm to the
patient resulting from inadvertent consumption of an unintended drug.
Objective: This study was conducted to analyze and list out common confusing drug pairs in the Nepalese market aiming
to increase awareness of such drug pairs among health care professionals.
Methods: Department of Drug Administration list of registered drugs, Nepal Drug Review, Monthly Index of Medical
Specialties and fi ndings from drug survey in the market were used as sources of the drugs analyzed in this study. Error
prone medication pairs that cause confusion while prescribing, dispensing and administration/consumption were sorted
Results: Such drug-pairs were regrouped into different categories in a manner that they depict the clinical signifi cance
of the type of error. Also real life experiences of medication errors and near misses due to error prone drug pairs were
collected from the doctors and the dispensers.
Conclusion: Several brand names are nearly identical; look alike sound alike drug pairs pose as an imminent danger to
medical practice. This problem can only be minimized by increasing awareness of the presence of such confusing drug
pairs among the healthcare professionals and increasing the feeling of shared responsibility by all the core members of
the health care team.
Key words: Identical, Look-alike, Medication error, Patient safety, Sound-alike
(Ciprofl oxacin, a Fluroquinolone), later on due to some Look alike sound alike drugs have even claimed reasons there was termination of pregnancy and the
lives due to error of administration of a different hospital was blamed for the inadvertent abortion. These drug other than the one prescribed. Few such cases are only a few instances of medication errors due to have surfaced at different times in different places. An look alike sound alike drugs. Some of us may have faced 8-year-old patient was prescribed Methylphenidate similar problem and may be looking for solution while (METADATE) for attention defi cit disorder; instead, others may not be aware of the danger similarities in the he received Methadone a similar looking drug and trade names pose to the medical practice.
died later. A 50-year-old woman with complaints of bronchospasm was hospitalized after taking FLOMAX, Our country Nepal, no matter how small, has a plethora a drug for enlarged prostate, instead of VOLMAX which of medicines at our disposal to put off the illnesses at bay relieves bronchospasm1. In Nepal, a case is recorded and this is especially true in big cities like Kathmandu. where a pregnant women who was prescribed the drug Department of Drug Administration, the government FOLVIN (Folic Acid) was instead dispensed FLONTIN body for registering drugs in Nepal states that as of today the total number of registered drugs in Nepal is well above over 10,000. Having different medicines to Address for correspondence
use certainly gives us numerous choices, the more the choice the higher is the chance that the right drug is Department of Pharmacology, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal However, with increasing number of medicines, slowly creeps in different problems, among them is a problem Vol. 2 • No. 2 • Issue 4 • Apr.-Jun. 2013 of confusing drug names. They may either lo ok-alike when the drug pairs differ in generic constitution while (orthographic) or sound-alike (phonological) and it is much lesser if such drug pairs belong to the same hence easily lead to medication errors at the time of dispensing or administration/consumption. This results in consumption of a medicine different than the one prescribed for the patient, end result being unmet Error prone medication pairs that can easily cause medical needs of the patient and rather unwanted confusion while prescribing, dispensing and effects from consumption of a different medicine. administration/consumption were sorted out. Also real life experiences of medication errors and near misses Confusing drug name pairs that look-alike or sound- due to error prone drug pairs were collected from alike are generally known as LASA medicines or sound- the doctors and the dispensers. Such pairs were then alike--look-alike drugs “SALAD”2. It is as one of the most regrouped into different groups so as to make them common causes of medication error worldwide3. There appear in a manner with clinical signifi cations- looking are many look-alike, sound alike medication pairs in into the type of impact they can make when events of different countries that can lead to medication errors. Such drug pairs are now increasingly being studied in 1. LASA drugs-Similar brand names, different generic much more detail at national level and at International level so as to reduce the medication error and hence 2. LASA drugs- Similar brand names, same generic 3. LASA drugs- Similar brand names with additional The Institute for Safe Medication Practices “ISMP”, USA is working on it since many years. It is compiling an ever growing list of LASA medicine name pairs, LASA drugs- Similar brand names of the Antibiotics with the latest one published in the year 20114. In our country in absence of any authorized agencies working 5. LASA drugs- Same drug, different Dosage forms for Medication Safety, there is no proper listing of such drugs. This is hereby, an attempt to compile a list in 6. LASA drugs- Same drug, different release context of Nepal and make the health care professionals aware of possible danger during use of such medicines. 7. LASA drugs- Same brand name, different composition, different country (Category VII) LASA drugs- Generic Drug pairs (Category VIII) Department of Drug Administration “DDA” list of registered drugs5, Nepal Drug Review “NDR6”, Monthly The drug pairs listed below only give a brief idea of the Index of Medical Specialties “MIMS7” and fi ndings from various types of LASA drug-pairs in the Nepalese market drug survey in the market were used as sources of the and represents only a tip of iceberg with many more submerged beneath. In fact the manual scanning of the drug-pairs without aid of specialized computer software The drug names were scanned for following characters led to the fi nding of over 200 drug pairs of similar looking brand names with same or different generic 1. LASA names which differ in one vowel only, e.g. composition, and if we include drug-pairs with additional letter, different dosage forms and release characteristics 2. LASA names which differ in one consonant only, e.g. it mounts well over 400. However, mentioning all those is beyond the scope of this paper. Therefore, below 3. LASA names differing in more than one letters, e.g. only the drug-pairs which are more common in use are selected as examples for representing their groups.
4. Similar names with additional letters, e.g. TRIAD, The drugs with similar brand names despite different generic composition pose a high risk to patient safety. Such pairs were then regrouped into different categories A prescription for ALMEX can at times look like ALMOX, as per their clinical signifi cance. The drug-pairs which hence the patient may consume Amoxicillin instead are more common in use are selected as examples for of Albendazole which certainly will not solve his/her representing their groups. Clinical impact is the largest problem of helminths. Similarly, a verbal or telephonic Vol. 2 • No. 2 • Issue 4 • Apr.-Jun. 2013 order for ACENIL may be noted as ACEPRIL, hence the leads to guess work during dispensing/administration patient in pain will still be in pain and rather may have Few drugs are prepared to have different release Category II drugs having the same generic composition characteristics as compared to conventional dosage do not cause much problem when one is dispensed forms. Sometimes immediate action may be wanted in place of other, except if the effi cacy of drugs from from a drug and hence a dispersible tablet may be different companies vary. The products with different prescribed. However, in country like ours where proprietary names for the same active ingredient may people at pharmacies may not have proper pharmacy education, may instead give a conventional tablet. Also 1. Two or more drugs of the same generic composition if a sustained release drug is prescribed and instead are prescribed simultaneously; chances of cases as conventional tablet is administered, it exposes a patient such is higher here in Nepal since the patients here to a high dose of instant release tablet, which may cause tend to visit different doctors till they are assured toxicity rather than the intended prolonged effect of the their problem will be solved, hence they may be drug. Therefore, prescriber explaining the patient about getting different brand drugs with same generic the type of medicine prescribed, one that works over composition and may be over dosing themselves.
a long time (SR) or the one that releases quickly when 2. A patient may be allergic to an active ingredient placed in water (DT), would make patient more vigilant but unknowingly takes it because the product has a to take the correct form of medicine reducing the errors.
There are chances that some medicines marketed under It has been seen that in cases of similar brand names same or similar-sounding brand names may contain with additional letter, the additional letter may denote different active moieties in different countries (Category the presence of additional substance along with the VII). The drug marketed by the name MELOL contains parent molecule, but at the same time may also refer Metoprolol in Nepal and is known to contain Atenolol to a different molecule itself as in case of TAXIM and and Amlodipine in India. This can be problematic if one TAXIM-O. The illegible handwriting of some prescribers practices medicine in India and prescribes the same may create confusion in dispensers and a different drug while here in Nepal; the actual drug taken by the patient is something different from the intended drug. Also this type of drug pairs may cause problem in the modern LASA drugs of the antibiotic groups are among the world, because the new generation often resort to highly confused ones. An assumption may be made that search the internet for things one is unsure of. So, having the drugs whose names end in suffi x "FLOX" may refer a drug registered by the same name with different to Ofl oxacin (ARFLOX, MEGAFLOX); however, it may not generic constituent somewhere else also increases the always be true and may also at times denote different chemical moieties like Flucloxacillin (PERIFLOX) and Ciprofl oxacin (MICROFLOX), so wrong assumption while When it comes to generic names, the degree of confusion prescribing or dispensing leads to a medication error.
is decreased but none-the-less is known to exist. Problematic generic drug name pairs that have surfaced We all are aware that drugs are available in different in one country often pose similar problem elsewhere dosage forms. Never-the-less, it is possible that few too. The drug pair Acetazolamide and Acetohexamide prescribers only deal with a particular form of medicine are problematic worldwide and they having posed a on a routine basis and hence do not fi gure out the problem in mountaineering groups in Nepal have also importance of mentioning the dosage form while been recorded8. Due to the fact that generic prescribing prescribing. However, for some drugs that exist in is limited only to a handful of hospitals in Nepal, errors different dosage forms, there arises a problem at the arising from similar generic names are not seen much time of dispensing. Failure to mention the dosage form, Vol. 2 • No. 2 • Issue 4 • Apr.-Jun. 2013 Table 1: LASA drugs-Similar brand names, different generic composition (Category I)
The strengths of the preparations are in milligrams (mg) until and unless stated to be otherwise. The slash “/” mark in strength section denotes the different strengths available in the market. Table 2: LASA drugs- Similar brand names, same generic composition (Category II)
Table 3: LASA drugs- Similar brand names with additional letter (Category III)
Table 4: LASA drugs- Similar brand names of the Antibiotics group (Category IV)
Vol. 2 • No. 2 • Issue 4 • Apr.-Jun. 2013 Table 5: LASA drugs- Same drug, different Dosage forms (Category V)
Table 6: LASA drugs- Same drug, different release characteristics (Category VI)
Table 7: LASA drugs- Same brand name, different composition, different country (Category VII)
Table 8: LASA drugs- Generic Drug pairs (Category VIII)
Acetohexamide - Acetazolamide
Folic acid - Folinic acid
Vol. 2 • No. 2 • Issue 4 • Apr.-Jun. 2013 DISCUSSION
for it. The example of LASA pair D AMOXY (Amoxicillin) The look-alike sound-alike drugs covered under different and DIAMOX (Acetazolamide); giving the wrong drug categories depict the potential of the problem we might certainly will not fulfi ll the intent with which one was be facing on a regular basis. Just a small glitch in the given and may cause harm from unabated illness to process of prescribing, dispensing or administering medicine can lead to medication error, which in turn may compromise patient safety.
There is also a trend of using a fanciful proprietary name for a drug to imply that the drug has some unique The fi rst seven categories discussed here are all related effectiveness or doing so helps memorize the name of to the trade names while the eight category is for the the drug. Similar cases can be traced here in Nepal; the generic drug pairs. LASA drugs problem is more common drug Mebendazole comes by the name KITKAT. At times, with trade names since they are specifi cally chosen so patient parties have rather come up with the chocolate that they sound pleasant, are easy to remember, catchy, Kit Kat instead when handed over a small chit transcribed and positive. This limits the combination of sounds that by the nurses for the drug KITKAT (Mebendazole).
can be used signifi cantly, which is why so many trade names are easily confused. The reason for lesser problem Avoiding the LASA drug related medication errors of LASA drugs in generic naming is because the generic does not only fall under the jurisdiction of a single naming is a process regulated by multiple agencies healthcare provider but requires a collaborative efforts which all try and make sure to provide a distinct name of prescribers, dispensers, administrators and even the Among the different categories of drugs mentioned A few universal factors like illegible prescription above, categories I, IV, VII and VIII which all have different writing, incompetent people at the pharmacies, generic constituents present much of a problem in incomplete knowledge of drug names, no knowledge events of occurrence of such errors. However, the of newly registered products, similarity in labeling and categories III and VI which have additional molecule packaging, similar clinical use, similar strengths, dosage or different release characteristics can also have forms, frequency of administration, and the failure of consequences which when occur can bring about manufacturers and administrative bodies to recognize some degree of negative impact in the patient. The potential for error are established cause for LASA drug problem associated with similar brand names despite the same generic constitution (Category II) is relatively low, provided that the medicine has equal potency. In Nepal most of the hospitals and clinics use the system Nevertheless one should not disregard the fact that this of prescribing in trade names and there are only a might lead to co-prescribing or co-administration of two handful of hospitals which have started prescribing different drugs with the same generic constituent at the in generics, trade names being more prone to LASA same time leading to over dosing problem. names. Complicating the things in Nepal is the scenario of medical transcription done at the end of the nursing The error arising from the failure to mention the dosage staff in many hospitals, who may not be adequately form (Category V) is known to occur to a much more versed with the disease condition and the drug being extent, arising from the regular prescribing of the same prescribed, thereby, leaving enough space for medication medication and feeling of decreased need of mentioning error. To make the matters much worse, the absence of the dosage form over and over again. Though it is prescription checking at the time of dispensing by the not such big a problem, however patients who were pharmacists certainly is another broken link in the health intended one dosage form may get another and effects care system in Nepal, which also adds to increase the POSSIBLE SOLUTIONS
LASA medicine related errors may not necessarily at all times harm the patient; such is the case when the 1. Identifi cation of LASA medications
active ingredient and indication are similar and the Create the awareness of look-alike and sound-alike difference only exists in the manufacturer, as in case of medicines in the prescribers; if possible provide a DECOLD (Lomus Pharmaceuticals- Nepal) and D ’COLD detailed list of drug names pairs in the local market and (Paras Pharma-India). However, not all patients may be those accepted internationally as published by various equally lucky and some might have to pay a high price agencies working for medication safety10. Feeling Vol. 2 • No. 2 • Issue 4 • Apr.-Jun. 2013 hared responsibility by all the health care team b. Formulate policies on verbal or telephonic members and the institution is a key factor to avoiding Formulating policies to accept verbal or telephonic orders only when truly necessary. 2. Prescriber’s
Encouraging staff to read back all orders, spell Minimize the use of verbal and telephonic prescription the product name, and state its indication12. order11, until and unless it cannot be completely avoided. Try and reduce the medical transcription by Try to use legible handwriting while prescribing, the nursing staff and rather initiate dispensing keeping in mind as if one was writing bank cheques12. only against a proper prescription by a licensed I t should be born in mind that the medicine best suited doctor14. Initiate measures to check the medicine for the patient may not give good results if confusion for indication, dose prior to dispensing and arises with drug name or instruction for taking it and administering the medicine. For any institution hence may instead cause more harm than good. While to formulate and work on such policy, it should writing prescriptions for drugs known to be problematic, get full support from its medical fraternity, so try and reduce the confusion by writing trade names again here the doctors might need to come (UPPER CASE) accompanied by generic names, dosage forward help the institution in such measures. form, strength, directions and indication for use when possible13. Mostly the confusing drugs are used for different purposes, knowing the indication can help prescribing the best medicine will do no good if mistake creeps in at the other end in dispensing 3. Pharmacist’s/dispenser’s
or administration of medicines. Therefore, in the They should not leave any doubt while dispensing long run hospitals should ensure prescription medicines, guess work is strictly prohibited. Provided legibility through improved handwriting and that there is dose and other details in the prescription printing, or use of printed order or electronic s/he should make use of his/her knowledge to identify the drug prescribed. In case of uncertainty in medicine names, they should not hesitate to consult the d. Cautious approach towards generic prescribing prescribing doctor before dispensing 12. In case of Nepal, pharmacies are known to work in haste, giving less time Taking a step towards generic prescribing to dispensing, which itself increases chances for error, so coupled with hospital formulary development slowly better systems should be incorporated to ensure to make recommendations of different brands to be used within the hospital. It is a well-accepted fact that research is carried out at a 4. Patient’s
much greater depth while naming generics of Literate patients can themselves check if the dispensed new medicines; hence confusion with similar product is the same as prescribed. Here, again the need names is lesser. However, in a country like ours for legibility of the prescription is highlighted. If in moving on to generic prescribing should be doubt, he/she should ask the pharmacist/dispenser for done with caution, since the presence of less verifi cation. Patients who cannot read and write should effi cacious drugs in the market is also high. Also better consult other sources for verifi cation before there is tendency of patient buying medicines not just from pharmacy at the hospital but from outside pharmacies which may be engaged in 5. Hospital’s or institution’s role
Provide education on potential LASA medicines Incorporating education on potential LASA Continuous upgrading of Hospital formulary medications into the educational curricula,
orientation, and continuing professional formulary, considering the possibility of adding development for health-care professionals and drug to form a confusing drug pair. If a potential annually review the list of LASA medicines used LASA drug is already present in the formulary, the less important drug in the LASA pair can be Vol. 2 • No. 2 • Issue 4 • Apr.-Jun. 2013 removed. If the addition is a must the institution the ever growing number of medicines being discovered must notify the prescribers of the confusing We therefore, should be able to recognize the prevalence of LASA medications and try our level best in decreasing the medication error by being committed to decreasing Making it mandatory for the “Name alert” errors arising as a result of such confusing drug pairs. stickers to be affi xed in areas where look-alike or sound-alike products are stored in pharmacies3. Minimization of verbal and telephonic errors is Keeping look alike drugs in adjoining shelves is something that can be commenced soon, so taking such known to have caused more error in dispensing. steps and slowly moving towards prescription legibility should be given a head start. Formulating policies on strictly prohibiting guess work in case of medical Setting up a system of reporting of errors and transcription and dispensing is another milestone that potentially hazardous conditions arising from can be covered. If we could raise the awareness in the look-alike and sound-alike drug pairs and using public, the educated patients would certainly be able to the information to establish priorities for error make sure that they take the correct drug. Institutions forming a “Medication safety committee” for monitoring new confusing drug pairs, and recommending new 6. Manufacturer’s and regulatory agency’s role
insights to bar such errors and formulating the policies at The manufacturers and regulatory agencies both should institutional level will be required to deal with errors as work together hand in hand to avoid confusion right such in the long run. The manufacturers and regulatory at the time of naming their products. The regulatory bodies should acknowledge the gravity of the problem agencies must develop strict mechanisms whereby such drug pairs can cause and follow stricter measures no drug-pairs looking or sounding similar come to the to ensure that such confusing names are not registered market. Any reports of confusing brand names should be taken seriously and proper steps should be taken towards renaming the drug. It is a common trend for The concept being that an error is something that can manufacturers to use part of their company names as be prevented, understanding the cause better, certainly suffi x or prefi x in the trade names of drugs they market, helps decreasing its occurrence and helps us move for different marketing reasons, but they should make towards implementing safer practices. Provided that sure that in doing so they are not contributing to the we could work to decrease in such medication errors it would serve as a milestone in increasing patient safety. In the past Royal Drugs had a panel of “naming This paper should serve as a cautionary approach for consultants”, who came up with unique names like AMGIT the prescribers to be self-aware of the potential hazards (Amoebiasis, Metronidazole, GIardiasis, Trichomoniasis); and also for our institution to try and form a “Medication NECYCLINE (Nepal-Tetracycline); CUFNAS (Against- safety committee” to deal with matters as such and “NAS” Cough) which easily grabbed the required many more which cause various kinds of medication attention from both prescribers and patients. May be its errors. Awareness is the fi rst step towards minimizing time that every other drug companies turn to panels of the occurrence of such errors; let us all be aware. “naming consultants” for creating a unique name that will appeal to both doctors and patients. They coming ACKNOWLEDGMENTS
up with names like ADVAIR, “advantage air for asthma”; I am thankful to all those who helped me in different SPASMINDON “Spasm relief from INDON” may possibly stages of data collection Shailesh Upadhyaya, Santosh help solve the problem, being both unique and catchy.
Karna, Pan Bahadur Chhetri (DDA), Safi ur Rehman Ansari, Ananta Sigdel. Likewise, I would like to extend CONCLUSION
my sincere gratitude to Professor Dr. Hemang Dixit, Ex- The look-alike and sound-alike drugs are available in the Principal, Kathmandu Medical College, for providing market today and will continue to bother us in future. me constructive feedback. Finally, thanks to all who The problem may even escalate by many folds owing to extended their helping hands without whose help the article would not have come to a meaningful end. Vol. 2 • No. 2 • Issue 4 • Apr.-Jun. 2013 REFERENCES
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as acute mountain sickness, after mistaking jointcommission.org/assets/1/18/SEA_19.pdf Vol. 2 • No. 2 • Issue 4 • Apr.-Jun. 2013
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