DRUG NAMES, LABELING, AND PACKAGING ASSOCIATED WITH MEDICATION ERRORS

To urge drug manufacturers, drug packagers and repackagers, outsourcing pharmacies, and the Food and Drug Administration to involve patients, practicing pharmacists, nurses, and physicians in decisions about drug names, labeling, and packaging to help eliminate (a) look-alike and sound-alike drug names, and (b) labeling and packaging characteristics that contribute to medication errors; further,

To inform pharmacists and others, as appropriate, about specific drug names, labeling, and packaging that have documented association with medication errors.

Rationale

Confusion caused by drug product names, labeling, and packaging has been associated with medication errors. Despite laws, regulations, and standards that seek to address these areas, safety concerns still exist. For example, the Institute for Safe Medication Practices lists errors and hazards due to look-alike labeling of manufacturer’s products third and unsafe labeling of prefilled syringes and infusions by 503B compounders eighth among the top ten medication errors and hazards. ASHP advocates involving representatives of those who use the products— patients, practicing pharmacists and pharmacy technicians, nurses, and physicians—in the decision-making process regarding drug names, labeling, and packaging to provide advice on how to avoid confusion and prevent medication errors. In furtherance of our mission to support pharmacists in helping people achieve optimal health outcomes, ASHP will continue to inform the pharmacy workforce, other healthcare providers, government agencies, and the public about specific drug names, labeling, and packaging associated with medication errors.