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Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names

BACKGROUND: Confusion between look-alike and sound-alike (LASA) medication names (such as mercaptamine and mercaptopurine) accounts for up to one in four medication errors, threatening patient safety. Error reduction strategies include computerized physician order entry interventions, and ‘Tall Man’...

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Detalles Bibliográficos
Autores principales: Bryan, Rachel, Aronson, Jeffrey K., ten Hacken, Pius, Williams, Alison, Jordan, Sue
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2015
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4689353/
https://www.ncbi.nlm.nih.gov/pubmed/26701761
http://dx.doi.org/10.1371/journal.pone.0145431
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author Bryan, Rachel
Aronson, Jeffrey K.
ten Hacken, Pius
Williams, Alison
Jordan, Sue
author_facet Bryan, Rachel
Aronson, Jeffrey K.
ten Hacken, Pius
Williams, Alison
Jordan, Sue
author_sort Bryan, Rachel
collection PubMed
description BACKGROUND: Confusion between look-alike and sound-alike (LASA) medication names (such as mercaptamine and mercaptopurine) accounts for up to one in four medication errors, threatening patient safety. Error reduction strategies include computerized physician order entry interventions, and ‘Tall Man’ lettering. The purpose of this study is to explore the medication name designation process, to elucidate properties that may prime the risk of confusion. METHODS AND FINDINGS: We analysed the formal and semantic properties of 7,987 International Non-proprietary Names (INNs), in relation to naming guidelines of the World Health Organization (WHO) INN programme, and have identified potential for errors. We explored: their linguistic properties, the underlying taxonomy of stems to indicate pharmacological interrelationships, and similarities between INNs. We used Microsoft Excel for analysis, including calculation of Levenshtein edit distance (LED). Compliance with WHO naming guidelines was inconsistent. Since the 1970s there has been a trend towards compliance in formal properties, such as word length, but longer names published in the 1950s and 1960s are still in use. The stems used to show pharmacological interrelationships are not spelled consistently and the guidelines do not impose an unequivocal order on them, making the meanings of INNs difficult to understand. Pairs of INNs sharing a stem (appropriately or not) often have high levels of similarity (<5 LED), and thus have greater potential for confusion. CONCLUSIONS: We have revealed a tension between WHO guidelines stipulating use of stems to denote meaning, and the aim of reducing similarities in nomenclature. To mitigate this tension and reduce the risk of confusion, the stem system should be made clear and well ordered, so as to avoid compounding the risk of confusion at the clinical level. The interplay between the different WHO INN naming principles should be further examined, to better understand their implications for the problem of LASA errors.
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spelling pubmed-46893532015-12-31 Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names Bryan, Rachel Aronson, Jeffrey K. ten Hacken, Pius Williams, Alison Jordan, Sue PLoS One Research Article BACKGROUND: Confusion between look-alike and sound-alike (LASA) medication names (such as mercaptamine and mercaptopurine) accounts for up to one in four medication errors, threatening patient safety. Error reduction strategies include computerized physician order entry interventions, and ‘Tall Man’ lettering. The purpose of this study is to explore the medication name designation process, to elucidate properties that may prime the risk of confusion. METHODS AND FINDINGS: We analysed the formal and semantic properties of 7,987 International Non-proprietary Names (INNs), in relation to naming guidelines of the World Health Organization (WHO) INN programme, and have identified potential for errors. We explored: their linguistic properties, the underlying taxonomy of stems to indicate pharmacological interrelationships, and similarities between INNs. We used Microsoft Excel for analysis, including calculation of Levenshtein edit distance (LED). Compliance with WHO naming guidelines was inconsistent. Since the 1970s there has been a trend towards compliance in formal properties, such as word length, but longer names published in the 1950s and 1960s are still in use. The stems used to show pharmacological interrelationships are not spelled consistently and the guidelines do not impose an unequivocal order on them, making the meanings of INNs difficult to understand. Pairs of INNs sharing a stem (appropriately or not) often have high levels of similarity (<5 LED), and thus have greater potential for confusion. CONCLUSIONS: We have revealed a tension between WHO guidelines stipulating use of stems to denote meaning, and the aim of reducing similarities in nomenclature. To mitigate this tension and reduce the risk of confusion, the stem system should be made clear and well ordered, so as to avoid compounding the risk of confusion at the clinical level. The interplay between the different WHO INN naming principles should be further examined, to better understand their implications for the problem of LASA errors. Public Library of Science 2015-12-23 /pmc/articles/PMC4689353/ /pubmed/26701761 http://dx.doi.org/10.1371/journal.pone.0145431 Text en © 2015 Bryan et al http://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.
spellingShingle Research Article
Bryan, Rachel
Aronson, Jeffrey K.
ten Hacken, Pius
Williams, Alison
Jordan, Sue
Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names
title Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names
title_full Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names
title_fullStr Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names
title_full_unstemmed Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names
title_short Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names
title_sort patient safety in medication nomenclature: orthographic and semantic properties of international nonproprietary names
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4689353/
https://www.ncbi.nlm.nih.gov/pubmed/26701761
http://dx.doi.org/10.1371/journal.pone.0145431
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