Linguistic Analysis of Generic-Generic Drug Name Pairs Prone to Wrong-Drug Errors for which Tall-Man Lettering is Recommended

OBJECTIVE: The Institute for Safe Medication Practices (ISMP) and the United States Food and Drug Administration (FDA) disseminated widely used lists of drug name pairs involved in wrong-drug errors, for which they recommended tall-man lettering (TML). Linguistic similarity is believed responsible for confusion of these drugs. This study aims to quantify linguistic similarity and other linguistic properties of these generic-generic name pairs. METHODS: The FDA’s Phonetic and Orthographic Computer Analysis (POCA) software was used to generate numerical similarity scores for the generic-generic name pairs on these lists and to identify conflicts between these names and the names of other marketed products. Within each pair, differences in name length and the number of identical prefix (initial) letters and suffix (final) letters were determined. RESULTS: The selected pairs shared a mean of 2.5 (± 1.8) identical prefix letters and 3.2 (± 2.9) identical suffix letters. The mean POCA score 69.5 (± 9.7), indicated moderate-to-high similarity. POCA scores for individual pairs ranged from 90 (most similar) to 46 (least similar). Individual names averaged 11.2 (± 9.1) high-similarity conflicts with names of other marketed drugs. CONCLUSIONS: POCA analysis could be a valuable tool in determining whether linguistic similarity contributes to specific wrong-drug errors. The finding of 11.2 (± 9.1) high-similarity conflicts with names of other marketed drugs is more than for candidate names USAN accepts and suggests the names on the FDA and ISMP lists are linguistically problematic.