What's in a Name? When It Comes to Drugs, Plenty
WEDNESDAY Aug. 6, 2008 -- You say tomato, I say tomahto.
Which is all well and good as long as we're talking about fruits and vegetables -- but not so good if the nurse says "fentanyl" and the hospital pharmacist hears "sufentanil," as happened to one patient preparing for an endoscopy.
The patient, given an opioid about 10 times more potent than the one prescribed, ended up in cardiopulmonary resuscitation.
The problem of sound-alike/look-alike drug names and its close cousin -- plain old mispronunciation -- abounds. The dilemma would almost be comical, except that people can die.
"[Mispronunciation] is more than a challenge, it's also a danger," said Robert Stanberry, assistant professor of pharmacy practice at Texas A&M Health Science Center Irma Lerma Rangel College of Pharmacy.
"If you pronounce it wrong, you may end up with the wrong drug," added Marilyn Storch, coordinator for all patient safety projects and the health care quality and information department at U.S. Pharmacopeia (USP), the official "standards-setting" authority for medications, dietary supplements and other health-care products sold in the United States.
And more words -- and syllables -- are entering the drug world all the time.
"As drugs proliferate, they start to sound alike, like Celexa and Celebrex," said Dr. Kennedy, director of geriatric psychiatry at Montefiore Medical Center in New York City. "It's just going to get worse with increases in the number of drugs and in the number of unfamiliar names."
Also, bear in mind that for countless physicians, many medications that they were trained to pronounce and prescribe when they were in medical school are no longer used, Kennedy added.
The Celexa/Celebrex combination is a classic example, but there are others. Losec, for heartburn, was confused so often with Lasix, a diuretic, that the name was changed to Prilosec. But now that gets confused with Prozac, according to a USP report.
And the Alzheimer's drug Reminyl was changed to Razadyne after mix-ups involving Amaryl, which lowers blood sugar. The mix-ups reportedly resulted in two deaths.
And what about names that are just too long? The generic name for Flurizan, an investigational Alzheimer's drug, is tarenflurbil. "It's almost too many syllables to pronounce," Kennedy said. Does anyone know how to pronounce bapineuzumab, another investigational drug for Alzheimer's?
The report issued earlier this year by USP on the relationship between drug names and medication errors reviewed more than 26,000 records. It found almost 1,500 different drugs implicated in medication errors as a result of names that looked or sounded alike. The drugs in question added up to 3,170 pairs, double the number of pairs found in a 2004 report. According to the document, 1.4 percent of the errors resulted in patient harm, including seven that may have played a part in patient death.
To be fair, there have been initiatives aiming to fix the problem, such as a pronunciation guide from the United States Adopted Names Council, and the "good naming practices" effort from the drug industry trade group PhRMA (Pharmaceutical Research and Manufacturers of America), not to mention the Unique Ingredient Identifier system being developed by USP and the U.S. Food and Drug Administration, as well as efforts to bar code all drugs.
Since 2002, the USP Nomenclature Expert Committee has been reviewing drug-name pronunciations to ensure consistency. The council actually changed the entry in the dictionary for ibuprofen to reflect a suggested pronunciation.
But what happens when globalism comes into play?
"As far as pronunciation of words, my experience is that it's pretty much all over the place," Stanberry said. Americans and the British pronounce "barbiturate" differently and both are right.
"Even if you were pronouncing something correctly, if you had a really deep Southern drawl, it's not going to sound the same. Or if you come in with an English accent or a French accent or a Texas accent, you may be pronouncing it correctly, but it's not going to sound the same," Storch said.
And sometimes, no one seems to know the correct pronunciation.
Stanberry recalls being at a conference last year and listening to a speaker repeatedly mispronounce a drug name -- or so he believed. "I thought, 'This guy's just mispronouncing this terribly, and he's the speaker.' But he actually studied under the guy who discovered the drug."
Then again, the speaker was British. Stanberry is American.
The Merck Manuals has a guide to drug-name pronunciations.
Posted: August 2008