Designing safe drug names

Drug Safety

Volumn 28, Issue 6, 2005, Pages 495-512

  Lambert, Bruce L ^a,b   Lin, Swu Jane ^a   Tan, Hiangkiat ^a  

^a UNIVERSITY OF ILLINOIS AT CHICAGO   (United States)

^b Department of Pharmacy Administration ^*  (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANISINDIONE; CILASTATIN PLUS IMIPENEM; CONJUGATED ESTROGEN; CYCLOBENZAPRINE; DICLOXACILLIN; DIRITHROMYCIN; ENDOCET; ETIRACETAM; FLUOCINOLONE ACETONIDE; INDOMETACIN; ISRADIPINE; LOPINAVIR PLUS RITONAVIR; MINOCYCLINE; OXYPHENCYCLIMINE; RHYNCHOPHYLLINE; ROSIGLITAZONE; SILDENAFIL; TESTOSTERONE; VERAPAMIL; WARFARIN;

AUTOMATION; CONFUSION; DECISION MAKING; DRUG DESIGN; DRUG INDUSTRY; DRUG MARKETING; DRUG SAFETY; FOOD AND DRUG ADMINISTRATION; MEDICAL DECISION MAKING; MEDICAL LITERATURE; MEDICAL RESEARCH; MEMORY; PERCEPTION; PRESCRIPTION; PRIORITY JOURNAL; PROPHYLAXIS; REVIEW; SHORT TERM MEMORY; SIMULATION; STIMULUS RESPONSE; UNITED STATES;

CONFUSION; DRUG LABELING; HUMANS; MEDICATION ERRORS; PHARMACEUTICAL PREPARATIONS; TERMINOLOGY;

EID: 22344457087     PISSN: 01145916     EISSN: None     Source Type: Journal    
DOI: 10.2165/00002018-200528060-00003     Document Type: Review

References (107)

1. Institute for Safe Medication Practices. ISMP Medication Safety Alert! Huntingdon Valley (PA): Institute for Safe Medication Practices, 2003
2. US Pharmacopeia. USP Quality Review. US Pharmacopeia March [online]. Available from URL: http://www.usp.org/reporting/review/qr76.pdf [Accessed 2001 Jul 19]
3. Hoffman JM, Proulx SM. Medication errors caused by confusion of drug names. Drug Saf 2003; 26 (7): 445-52
4. Barker KN, Flynn EA, Pepper GA, et al. Medication errors observed in 36 health care facilities. Arch Int Med 2002; 162: 1897-903
5. Phillips J, Beam S, Brinker A, et al. Retrospective analysis of mortalities associated with medication errors. Am J Health-Syst Pharm 2001 October 1, 2001, 58
6. Aronson JK. Confusion over similar drug names: problems and solutions. Drug Saf 1995; 12 (3): 155-60
7. Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc (Wash) 2003 Mar-Apr; 43 (2): 191-200
8. University of Florida College of Pharmacy and PMC Quality Commitment I. CQI compliance guide for Florida pharmacists. Gainesville (FL): University of Florida, 2003
9. Kreling DH, Mott DA, Wiederholt JB, et al. Prescription drug trends: a chartbook. Washington (DC): The Henry J. Kaiser Family Foundation, 2000
10. National Association of Chain Drug Stores. 2002 community pharmacy results. National Association of Chain Drug Stores [online]. Available from URL: http://www.nacds.org/wm-spage.cfm?.parm1 = 505 [Accessed 2004 Mar 2]
11. Lambert BL, Yu C, Thirumalai M. A system for multi-attribute drug product comparison. J Med Syst 2004; 28 (1): 29-54
12. Medical Error Recognition and Revision Strategies, Inc. Services [online]. Available from URL: http://www.med-errs.com [Accessed 2004 Jan 14]
13. Lambert BL, Chang KY, Lin SJ. Effect of orthographic and phonological similarity on false recognition of drug names. Soc Sci Med 2001; 52: 1843-57
14. Lambert BL, Chang K-Y, Gupta P. Effects of frequency and similarity neighborhoods on pharmacists' visual perception of drug names. Soc Sci Med 2003; 57: 1939-55
15. Lambert BL, Chang KY, Lin SJ. Immediate free recall of drug names: effects of similarity and availability. Am J Health-Syst Pharm 2003; 60: 156-68
16. US Food and Drug Administration. Evaluating drug names for similarities: methods and approaches [public meeting]. US Food and Drug Administration 2003 Jun 26 [online]. Available from URL: http://www.fda.gov/cder/meeting/drugNaming. htm [Accessed 2004 Jan 14]
17. US Food and Drug Administration. Drug safety and risk management advisory committee meeting. US Food and Drug Administration 2004 Dec 4 [online]. Available from URL: http://www.fda.gov/ohrms/dockets/ac/03/slides/4007s1.htm [Accessed 2003 Jan 14]
18. Cohen M. Medication errors. Washington (DC): American Pharmaceutical Association, 1999
19. United States Adopted Names Council. USP Dictionary of USAN and international drug names. Rockville (MD): U. S. Pharmacopeia, Inc., 1998
20. Boring D. The development and adoption of nonproprietary, established, and proprietary names for pharmaceuticals. Drug Inf J 1997; 31: 621-34
21. Schwab M, Oetzel C, Morike K, et al. Using trade names: a risk factor for accidental drug overdose. Arch Intern Med 2002 May 13; 162 (9): 1065-6
22. Medicines and Healthcare Products Regulatory Agency. Product information: changing substance names from BANs to rINNs. MHRA [online]. Available from URL: http://medicines.mhra.gov.uk/inforesources/productinfo/banrinn.htm [Accessed 2004 Apr 29]
23. Lambert BL, Chang KY, Lin SJ. Descriptive analysis of the drug name lexicon. Drug Inf J 2001; 35: 163-72
24. US Patent and Trademark Office. Trademarks Registered. U.S. Patent and Trademark Office: Office of Electronic Information Products 1999 Feb [online]. Available from URL: http://www.uspto.gov/web/offices/ac/ido/oeip/catalog/ tmcassis.htm#TMregistered [Accessed 1999 Jun 15]
25. World International Property Organization. International (Nice) Classification of Goods and Services for the Purposes of the Registration of Marks. World International Property Organization [online]. Available from URL: http://www.wipo.org/classifications/fulltext/nice8/enmain.htm [Accessed 2004 Jan 15]
26. National Center for Health Statistics. Ambulatory Health Care Data: NAMCS Description. National Center for Health Statistics [online]. Available from URL: http://www.cdc.gov/nchs/about/major/ahcd/namcsdes.htm [Accessed 2001 May 31]
27. National Center for Health Statistics. Ambulatory Health Care Data: NHAMCS Description. National Center for Health Statistics [online]. Available from URL: http://www.cdc.gov/nchs/about/major/ahcd/nhamcsds.htm [Accessed 2001 May 31]
28. IMS Health. NPA Plus: National prescription audit. Westport (CT): IMS Health, Inc., 2003
29. Solucient Inc. Hospital drug utilization database. Solucient [online]. Available from URL: http://www.solucient.com/solutions/Solucients_Databases. shtml [Accessed 2004 Mar 5]
30. US Food and Drug Administration. Electronic Orange Book data files. US Food and Drug Administration [online]. Available from URL: http://www.fda.gov/ cder/orange/obreadme.htm [Accessed 2003 Jan 28]
31. Multum Information Services Inc. The Multum Lexicon. Multum Information Services Inc. [online]. Available from URL: http://www.multum.com/Lexicon.htm [Accessed 2003 Jan 28]
32. Ehrgott M, Gandibleux X. Multiple criteria optimization: state of the art annotated bibliographic surveys. Norwell (MA): Kluwer Academic, 2002
33. Triantaphyllou E. Multi-criteria decision making methods: a comparative study. Norwell (MA): Kluwer Academic, 2000
34. Wheaton M. Multiple goal decision analysis II [online]. Available from URL: http://sunset.usc.edu/classes/cs510_2003/notes/ec-files/bigproject1618.ppt [Accessed 2004 Jan 21]
35. Phillips J. The name game: new realities at FDA. Pharmaceutical Executive 2000 Jul: 66-69
36. Boring DL. The CDER labeling and nomenclature committee: structure, function, and process. Drug Inf J 1997; 31: 7-11
37. Jurafsky D, Martin JH. Speech and language processing: an introduction to natural language processing, computational linguistics, and speech recognition. Upper Saddle River (NJ): Prentice Hall, 2000
38. Miller GA. The science of words. New York: Scientific American Library, 1991
39. Pierce JR. An introduction to information theory: symbols, signals and noise. New York: Dover, 1980
40. Manell R, Cox F. The syllable and phonotactic constraints [online]. Available from URL: http://www.ling.mq.edu.au/units/ling210-901/phonology/ syllable/syll_phonotactic.html [Accessed 2004 Mar 5]
41. United States Adopted Names Council. USAN Handbook 5. 5th ed. Chicago (IL): USAN Council, 1999
42. US Patent and Trademark Office. Trademark manual of examining procedure. 3rd ed. US Patent and Trademark Office [online]. Available from URL: http://www.uspto.gov/web/offices/tac/tmep/foreword.htm [Accessed 2004 Jan 23]
43. Kane SD. Trademark law: a practitioner's guide. 3rd ed. New York: Practising Law Institute, 1997
44. Code of Federal Regulations. Drugs: statement of ingredients [online]. Available from URL: http://www.accessdata.fda.gov/ scripts/cdrh/cfdocs/cfCFR/ CFRSearch.cfm?.FR = 201.10 [Accessed 2004 Jan 23]
45. Health Canada LA/SA Working Group. Issue analysis summary: look-alike sound-alike (LA/SA) health product names: the development of a comprehensive policy recommendation. Policy and Promotion Division, Centre for Policy and Regulatory Affairs, Biologics and Genetic Therapies Directorate, Health Canada [online]. Available from URL: http://www.hcsc.gc.ca/hpfb-dgpsa/bgtd-dpbtg/ lookalike_soundalike_ias_e.pdf [Accessed 2004 Apr 26]
46. Health Canada. Executive summary: look-alike sound-alike (LA/SA) health product names consultative workshop. Health Canada [online]. Available from URL: http://www.hcsc.gc.ca/hpfb-dgpsa/bgtd-dpbtg/summary_consultation_worktics shop_e.html [Accessed 2004 Mar 2]
47. European Agency for the Evaluation of Medicinal Products. Guideline on the acceptability of invented names for human medicinal products processed through the centealized procedure. EMEA Human Medicines Evaluation Unit 2002 Jan [online]. Available from URL: http://www.emea.eu.int/pdfs/human/regaffair/ 032898en.pdf [Accessed 2004 Apr 28]
48. Morrin M, Jacoby J. Trademark dilution: empirical measures for an elusive concept. Journal of Public Policy and Marketing 2000; 19 (2): 265-76
49. Howard DJ, Kerin RA, Gengler C. The effects of brand name similarity on brand source confusion: implications for trademark infinrgement. Journal of Public Policy and Marketing 2000; 19 (2): 250-64
50. Pharmacia Corp. vs Alcon Laboratories, Inc. 201 F. Suppl 2d 335 (D.N.J. 2002); 2002
51. Andrews S. The effect of orthographic similarity on lexical retrieval: resolving neighborhood conflicts. Psychon Bull Rev 1997; 4 (4): 439-61
52. Lexicon Branding I. Our methodology. Lexicon Branding. Inc. [online]. Available from URL: http://www.lexicon-branding.com/process4bAppproach.html [Accessed 2004 Feb 9]
53. Proulx SM. The Med-E.R.R.S. trademark process [online]. Available from URL: http://www.fda.gov/cder/meeting/DrugName/FDA%20trademark%20workshop/index. htm [Accessed 2004 Feb13]
54. Shangraw R. Expert committees 2003 Jun 26 [online]. Available onfrom URL: http://www.fda.gov/cder/meeting/DrugName/Shangraw%20-%20Expert%20Committees/ index.htm [Accessed 2004 Mar 2]
55. Diamond S. Screening proprietary drug names for similarities: research design and questionnaire structure [online]. Available from URL: http://www.fda.gov/cder/meeting/DrugName/sdiamond/index.htm [Accessed 2004 Mar 5]
56. Lambert BL. Predicting look- and sound-alike medication errors. Am J Health-Syst Pharm 1997; 54: 1161-71
57. Lambert BL, Chang KY, Gupta P. Effects of frequency and similarity neighborhoods on pharmacists' visual perception of drug names. Soc Sci Med 2003; 57: 1939-55
58. Zobel J, Dart P. Phonetic string matching: lessons from information retrieval. In: Frei HP, Harman D, Schauble P, et al., editors. 19th Annual International ACM SIGIR Conference on Research and Development in Information Retrieval; 1996 Aug 18-22; Zurich, Switzerland; New York: Association for Computing Machinery, 1996: 166-172
59. Salton G, McGill M. Introduction to modern information retrieval. New York: McGraw-Hill, 1983
60. Lambert BL, Yu C, Thirumalai M. A system for multi-attribute drug product comparison. J Med Syst 2004; 28 (1): 29-54
61. Lambert BL, Lin SJ, Gandhi SK, et al. Similarity as a risk factor in drug name confusion errors: the look-alike (orthographic) and sound-alike (phonological) model. Med Care 1999; 37 (12): 1214-25
62. Interagency Coordinating Committee on the Validation of Alternative Methods. Validation and regulatory acceptance of toxicological test methods. Research Triangle Park (NC): National Institute of Environmental Health Sciences; 1997 Mar. NIH Report no.: 97-3981
63. Dorr B, Kondrak G. Automatic string matching for reduction of drug name confusion [online]. Available from URL: http://www.fda.gov/ohrms/dockets/ac/03/ slides/4007S1_03_Dorr_files/frame.htm [Accessed 2004 Feb 11]
64. Kondrak G, Dorr B. A similarity-based approach and evaluation methodology for reduction of drug name confusion. College Park (MD): University of Maryland, 2003 LAMP-TR-110, CS-TR-4549, UMIACS-TR-2003-117
65. Fletcher R, Fletcher SW, Wagner EH. Clinical epidemiology: the essentials. Baltimore (MD): Williams & Wilkins, 1996
66. Hulley SB, Cummings SR. Designing clinical research. Baltimore (MD): Williams & Wilkins, 1988
67. Voorhees EM, Harman D. Overview of the sixth text retrieval conference (TREC-6). In: Voorhees EM, Harman D, editors. The sixth text retrieval conference (TREC-6); 1998 Nov 19-21; Gaithersburg (MD): National Institute of Standards and Technology, 1998: 1-24
68. Cohen MR. Drug product characteristics that foster drug-use system errors. Am J Health-Syst Pharm 1995; 52: 395-9
69. Fisher WM, Fiscus JG, Martin A, et al. Further studies in phonological scoring. Proceedings of the Spoken Language Systems Technology Workshop: 1995 Jan 22-25; Austin (TX): 181-186
70. ISMP medication safety alert: community/ambulatory care edition Vol.2, Issue 9 [computer program]. Version. Huntingdon: Institute for Safe Medication Practices, 2003
71. Jaszczak J. Evaluating drug name similarities applying hand-writing technologies. Parascript, LLC [online]. Available from URL: http://www.fda.gov/ cder/meeting/DrugName/FDA_DrugNameEval_final/ [Accessed 2004 Apr 28]
72. Luce PA, Pisoni DB. Recognizing spoken words: the neighbormaceutical hood activation model. Ear & Hearing 1998; 19 (1): 1-36
73. Fisher WM, Fiscus JG. Better alignment procedures for speech recognition evaluation. Proceedings of the International Conference on Acoustics, Speech and Signal Processing: 1993 Apr 27-30; Minneapolis (MN): 59-62
74. Fisher WM. aldistsm-1.2. National Institute of Standards [onfrom line]. Available from URL: http://www.nist.gov/speech/tools/aldistsm-12tarZ.htm [Accessed 2004 Mar 3]
75. Tversky A. Features of similarity. Psychol Rev 1977; 84 (4): 327-52
76. Weeds J. Asymmetry in similarity between words, 2002 [online]. Available from URL: http://www.informatics.sussex.ac.uk/users/pgrep/whp/doc/data/15/ contrib/juliewe/main.ps [Accessed 2005 Apr 27]
77. Ortony A, Vondruska RJ, Foss MA, et al. Salience, similes, and the asymmetry of similarity. J Mem Lang 1987; 24 (5): 569-94
78. Pegg JE, Werker JF. Adult and infant perception of two English phones. J Acoust Soc Am 1997 Dec; 102 (6): 3742-53
79. Slack M. Drug name confusion. Lancet 1991; 338: 190-1
80. Solomon RL, Postman L. Frequency of usage as a determinant of recognition threshold for words. J Exp Psychol 1952; 43: 195-210
81. Hall JF. Learning as a function of word frequency. Am J Psychol 1954; 67: 138-40
82. Howes DH. On the relation between the intelligibility and frequency of occurrence of English words. J Acoust Soc Am 1957; 29: 296-305
83. Savin HB. Word-frequency effect and errors in the perception of speech. J Acoust Soc Am 1963; 35: 200-6
84. Hulme C, Roodenrys S, Schweickert R, et al. Word-frequency effects on short-term memory tasks: evidence for a redintegration process in immediate serial recall. J Exp Psychol Learn Mem Cogn 1997; 23 (5): 1217-32
85. Monsell S. The nature and locus of word frequency effects in reading. In: Besner D, Humphreys GW, editors. Basic processes in reading: visual word recognition. Hillsdale (NJ): Erlbaum, 1991: 148-97
86. Grainger J. Word frequency and neighborhood frequency effects in lexical decision and naming. J Mem Lang 1990; 29: 228-44
87. Gregg V. Word frequency, recognition, and recall. In: Brown J, editor. Recall and recognition. New York: John Wiley & Sons, 1976: 183-216
88. Glanzer M, Bowles N. Analysis of the word-frequency effect in recognition memory. J Exp Psychol [Hum Learn] 1976; 2 (1): 21-31
89. Grainger J, Jacobs AM. Orthographic processing in visual word recognition: a multiple read-out model. Psychol Rev 1996; 103 (3): 518-65
90. Luce PA, Pisoni DB, Goldinger SD. Similarity neighborhoods of spoken words. In: Altmann GTM, editor. Cognitive models of speech processing: psycholinguistic and computational perspectives. Cambridge (MA): MIT Press, 1990: 122-47
91. Lambert BL. Apparatus, method, and product for multi-attribute drug comparison. US patent 6,529,892; 2003 Mar 4
92. Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 1995; 21 (10): 541-8
93. Gernsbacher MA. Resolving 20 years of inconsistent interactions between lexical familiarity and orthography, concreteness, and polysemy. J Exp Psychol Gen 1984; 113: 256-81
94. Gernsbacher MA. Handbook of psycholinguistics. San Diego (CA): Academic Press, 1994
95. Flynn EA, Barker KN. Medication errors research. In: Cohen M, editor. Medication errors. Washington (DC): American Pharmaceutical Association, 1999: 6.1-6.30
96. Barker KN, McConnell WE. How to detect medication errors. Mod Hosp 1962 Jul; 99: 95-106
97. Hennessy S. Quantitative evaluation of drug name safety using close-to-reality simulated pharmacy practice [online]. Available from URL: http://www.fda.gov/ohrms/dockets/ac/03/slides/4007S1_07_Hennessy.htm [Accessed 2004 Feb 13]
98. Heylighen F, Joslyn C, Turchin V. Optimization. Principia Cybernetica Web [online]. Available from URL: http://pespmc1.vub.ac.be/ASC/OPTIMIZATIO.html [Accessed 2004 Jan 15]
99. Chen Z, Burns S. Multiple objective optimization methods. Department of Mechanical Engineering, University of Victoria [online]. Available from URL: http://www.me.uvic.ca/∼zdong/courses/mech620/multi_opt.PDF [Accessed 2004 Feb 10]
100. Das I. Multi-objective optimization. Optimization Technology Center, Argonne National Labs and Northwestern University [online]. Available from URL: http://www-fp.mcs.anl.gov/otc/Guide/OptWeb/multiobj/index.html [Accessed 2004 Feb 10]
101. Lee EK. Optimization with multiple objectives. Department of Industrial and Systems Engineering, Georgia Institute of Technology [online]. Available from URL: http://www.isye.gatech.edu/nci-nsf.orart.2002/pdf-files/talk4.lee.pdf [Acment cessed 2004 Feb 10]
102. Jones DF, Tamiz M. Goal programming in the period 1990-2000. In: Ehrgott M, Gandibleux X, editors. Multiple criteria optimization: state of the art annotated bibliographic surveys. Norwell (MA): Kluwer Academic, 2002: 129-70
103. Tanino T, Kuk H. Nonlinear multiobjective programming. In: Ehrgott M, Gandibleux X, editors. Multiple criteria optimization: state of the art annotated bibliographic surveys. Norwell (MA): Kluwer Academic, 2002: 71-128
104. Grasha AF. Into the abyss: seven principles for identifying the causes of and preventing error in complex systems. Am J Health-Syst Pharm 2000; 57 (Mar 15): 554-64
105. Grasha AF, O'Neill M. Cognitive processes in medication errors. U.S. Pharmacist 1996; June: 1-9
106. Grasha AF, Schell K. Psychosocial factors, workload, and human error in a simulated pharmacy dispensing task. Percept Mot Skills 2001; 92: 53-71
107. Cohen MR, Anderson RW, Attilio RM, et al. Preventing medication errors in cancer chemotherapy. Am J Health Syst Pharm 1996 Apr 1; 53 (7): 737-46