and design approaches that will best support various consumer groups in their medication self-management.

  • AHRQ should fund studies to evaluate the impact of free samples on overall patient safety, provider prescribing practices, and consumer behavior (e.g., adherence to the medication regimen), as well as alternative methods of distribution that can improve safety, quality, and effectiveness.

Naming, Labeling, and Packaging

Drug names that look or sound alike increase the risk of medication errors (Cohen, 2000). Confusion over the similarity of drug names for prescription, generic, and over-the-counter (OTC) products accounts for up to 25 percent of all errors reported to the U.S. Pharmacopeia (USP) (NCC MERP, 2001). Abbreviations, acronyms, certain dose designations, and other symbols used for labeling also have caused a number of errors (FDA, 2005b). Even the layout and presentation of drug information on the drug container or package label can be visually confusing, particularly when designed for the marketplace instead of clinical practice. From January 2000 to March 2004, close to 32,000 reports were submitted to USP’s MedMarx Reporting System that linked errors to look-alike or sound-alike drug names (Santell and Camp, 2004). The Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) National Patient Safety Goals reference several look-alike/sound-alike generic drug names that have contributed to 9 of 10 serious medication errors in the hospital setting (JCAHO, 2006). And labeling and packaging issues were cited as the cause of 33 percent of errors, including 30 percent of fatalities, reported to the USP–Institute for Safe Medication Practices (ISMP) Medication Error Reporting Program (MERP) database (USP, 1998). Box 6-2 outlines the major problems in drug naming, labeling, and packaging that contribute to medication errors. Addressing these problems requires understanding the processes and requirements involved in naming, labeling, and packaging drug products.

Drug naming is a complex process. Each drug has multiple names assigned by different organizations for different purposes (Berman, 2004). The chemical name is assigned by the International Union of Pure and Applied Chemistry and identifies molecular structure. It serves the needs of scientific researchers. The nonproprietary or generic name is assigned by the United States Adopted Name Council (USAN) using a series of guidelines to ensure uniformity and safety.2 These guidelines require that the


The World Health Organization (WHO) coordinates international efforts to create a single worldwide standard and has established an International Nonproprietary Name (INN) for every product (Berman, 2004).

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