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Year : 2005  |  Volume : 51  |  Issue : 1  |  Page : 3-4

From the pen to the patient: Minimising medication errors

1 Department of Medicine, Seth GS Medical College and KEM Hospital, Parel, Mumbai - 400012, India
2 Departments of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Parel, Mumbai - 400012, India

Correspondence Address:
N J Gogtay
Departments of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Parel, Mumbai - 400012
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Source of Support: None, Conflict of Interest: None

PMID: 15793329

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How to cite this article:
Mehta S, Gogtay N J. From the pen to the patient: Minimising medication errors. J Postgrad Med 2005;51:3-4

How to cite this URL:
Mehta S, Gogtay N J. From the pen to the patient: Minimising medication errors. J Postgrad Med [serial online] 2005 [cited 2023 Sep 29];51:3-4. Available from:

Medication errors that lead to iatrogenic injuries are a well-known worldwide phenomenon and are common, costly, and clinically important.[1],[2] In 1910, Richard Clark published the first study that looked at error rates in clinical diagnosis.[3] Since then, several studies have looked at the problem of medication errors. Incidence rates of adverse drug events amongst adults admitted to the hospital have ranged from 2 to 7 per 100 admissions.[4],[5] Approximately, 28% of adverse drug events (ADEs) are related to medication errors and are, therefore, judged to be preventable.[6] This issue has also received considerable attention in the lay press. Over a period of time, there has been a transition from an era where medical practice and its practitioners were revered to a time when doubt and fear is expressed and legal suits are pursued by aggreived patients.[7] Heightened awareness of the problem of iatrogenic error has also resulted from the publication from the Institute of Medicine (IOM) "To Err is Human- Building a Safer Health system" released in 2000 wherein it was estimated that about 44,000 to 98,000 preventable deaths each year result from medical errors.[8]

In the present issue of the journal, two papers have addressed the issue of medication errors directly and indirectly. Rataboli et al[9] in an interesting study have analysed look-alike and sound-alike brands of drugs available in the Indian market. They have based their study on the list of drugs mentioned in the Indian Drug Review and Monthly Review of Medical Specialities and some brands that are not listed in the two books, but are available with the chemists. They have systematically divided these drugs into twelve different categories based on the nature of the drug, the dosage form, the similarities and the manufacturer. The classification is based on visual similarity in names, phonetic similarity or similarity in the looks. The 12 categories are those in which prescribing errors can result with some categories being more harmful than the others. The study is of importance in a country like India, where a choice needs to be made not only from 11 angiotensin-converting enzyme (ACE) inhibitors for example, but also probably 11 or more brands of each of the ACE inhibitors! Another study by Patel et al in the same issue of the journal has looked at the quality of prescriptions in Goa in western India.[10] It is noteworthy that single issue of the journal is carrying two original articles on this subject, a topic that has not been studied or reviewed regularly by healthcare professionals in this country.

Look-alike or sound-alike (LA/SA) health products refer to names of different health products that have orthographic similarities and/or similar phonetics (i.e. similar when written or spoken). These similarities may pose a risk to health by contributing to medical errors in prescribing, documenting, dispensing or administering a product. These medication errors may be more likely to occur because of contributing factors such as identical doses, dosage forms or routes of administration, similar packaging or labeling, incomplete knowledge of drug names, illegible handwriting, verbal order errors and even lack of an appropriate knowledge-base. Some of the brand names may not sound-alike when read out or look-alike when in print, but when hand written or communicated verbally they can cause confusion. Confusion regarding drug names is thought to account for 25% of all medication errors.[11] However, while each category listed by Rataboli et al represents an area for potential error, the number of drugs listed in each category is small and merely representative. One test, the Levenshtein distance, has been used to predict error pairs. An example of how this works is given by comparing Lamictal (lamotrigine) and Lamisil (terbinafine).[12] To transform Lamisil into Lamictal, the S is changed to a C, the I is changed to an A and the T is added. Three edit operations are required, giving a Levenshtein distance between the two names of three. The lower the distance, the more similar the drug names are. A threshold for Levenshtein distances has been proposed as greater than 5, therefore this test may have predicted the problems associated with Lamisil and Lamictal.

Reducing medication errors is a process of continous quality improvement. The journey from the pen to the patient is a long one and filled with multiple areas where errors can be made. The delivery of medical care like all other systems is safe only when human error is recognized as an inevitable consequence and systems are put in place to minimise consequences.[7] Current systems are not designed to capture errors and near errors because reporting is voluntary and systems for reporting do not exist.[13] What should be done is generally known as the five rights - the right drug, right dose, right route, right time and right patient.[14] Analysis of medication errors suggests that prevention strategies that target systems rather than individuals are most effective in reducing errors.[15] Today, more than ever, health care has become a team activity with multiple stakeholders. While the physician still remains the driving force, inputs from clinical pharmacists, nurses, and other healthcare professionals is often helpful. Computerised Physician Order Entry (COPE) and Clinical Decision Support Systems (CDSS) are promising systems, but need to be balanced against an initial expenditure that must be borne for long term benefits, which in turn need to be monitored and measured.[16] Use of standard protocols and guidelines coupled with academic education promote a more consistent approach to patient care and these should be put in place. Breakdown in communication is a common cause of harm to patients[17] and this needs to be addressed at several levels. Patel et al have not addressed an important area, that of undergraduate curriculum and postgraduate training. It is vital to evaluate the prescription writing skills acquired by students.[18] The issue of medication errors in India is extremely complex and goes much beyond brand names and phonetics since generic brands offer the considerable advantage of quality combined with cost effectiveness in the treatment of a variety of diseases.[19] Much has been done to date and much more is being done. Finally, it is important to work in conjunction with the most important stakeholder- the patients and help them understand the risks involved in healthcare and work with them to reduce harm.

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1.Lesar TS, Lomaestro BM, Pohl H. Medication prescribing errors in a teaching hospital: a 9 year experience. Arch Intern Med 1997;157:1569-76.  Back to cited text no. 1  [PUBMED]  
2.Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA 1997;277:301-6.  Back to cited text no. 2  [PUBMED]  
3.Gore DC, Gregory SR. Historical perspective on medical errors: Richard Cabot and the Institute of Medicine, J Am Coll Surg 2003;197: 609-11.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Bates DW, Boyle DL, Vander Vilet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Int Med 1995;10:199-205  Back to cited text no. 4    
5.Jha AK, Kuperman GJ, Teich JM, Leape L, Shea B, Rittenberg E, et al. Identifying adverse drug events: development of a computer based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 1998;5:305-14.  Back to cited text no. 5    
6.Bates DW, Cullen D, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274:29-34.  Back to cited text no. 6    
7.Ferner RE. Medication errors that hare led to manslaughter charges. BMJ 2000;321:1212-6.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Institute of Medicine: To err is Human : Building a safer health system. Washington DC: National Academy Press; 1999.  Back to cited text no. 8    
9.Rataboli PV, Garg A. Confusing brand names: Nightmare of medical profession. J Postgrad Med 2005;51:13-6.  Back to cited text no. 9  [PUBMED]  
10.Patel V, Vaidya R, Naik D, Borker P. Irrational drug use in India: A prescription survey from Goa. J Postgrad Med 2005;51:9-12.  Back to cited text no. 10  [PUBMED]  
11.Lambert BL, Linn SJ, Chang KY, Gandhi SK. Similarity as a risk factor in drug-name confusion errors: the look-alike (orthographic) and sound-alike (phonetic) model. Med Care 1999;37:1214-25.  Back to cited text no. 11    
12.Lambert BL. Predicting look-alike and sound-alike medication errors. Am J Health Syst Pharm. 1997;54:1161-71.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events : a problem for quality improvement (abstract). Jt Comm Qual Improv 1995;21:541-8.  Back to cited text no. 13  [PUBMED]  
14.Benjamin DM. Reducing medication errors and increasing patient safety: case studies in clinical pharmacology. J Clin Pharmacol 2003;43:768-83  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43.  Back to cited text no. 15    
16.Kaushal R, Kaveh GS, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety. Arch Intern Med 2003;163:1409-16.  Back to cited text no. 16    
17.Wilson T, Shaikh A. Enhancing public safety in primary care. Br Med Jr 2002;324:584-7.  Back to cited text no. 17    
18.Ferner RE. Medicines management: a sour taste. QJM 2002;95:181-4.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Dyer O. New 20 year patents threaten to end AIDS drugs for developing countries. BMJ 2004;329:1308.  Back to cited text no. 19    

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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow