One physician’s faxed order to discontinue hydrocodone, marketed as Anexsia, was misread by the pharmacist as an order to discontinue Arixtra, an anticoagulant. Another doctor intended to electronically order clonidine, an antihypertensive, but accidentally ordered the sedative clonazepam because both appeared as “CLON” on the computer screen.
These are just two of the 3,170 pairs of drug names that look or sound alike and can result in medication errors. They were found in a recent U.S. Pharmacopeia review of more than 26,000 patient records submitted over three years by 870 health care organizations. That total is nearly double the 1,750 similarly named drug pairs identified in a 2004 report issued by USP, a Rockville, Md.-based nonprofit standards-setting organization.
The whole shebang.