Earlier this summer ISMP updated its list of commonly confused drug names (ISMP 2011a). Then last month ISMP reported a mixup of Durasal (a salicylate-containing wart removal solution) with Durezol (a steroid eye drop preparation) that resulted in serious harm to a patient’s eye (ISMP 2011b).
That drug pair is on ISMP’s updated list. However, a potential mixup we recently mentioned between Pradaxa and Plavix as reported by ISMP Canada (see our July 2011 What’s New in the Patient Safety World column “First Thoughts on Dabigatran”) is not yet on the ISMP list.
The ISMP list is a most valuable resource. The recently confused drug pair (Durasal/Durezol) illustrates though that pharmacies need to periodically review drugs in their formularies that have been implicated in such LASA errors. That ISMP alert also points out the barriers in mobilizing appropriate responses when such dangerous situations are identified and the long periods that may elapse before appropriate actions are taken.
ISMP. ISMP”s List of Confused Drug Names. Updated through June 2011.
ISMP. Durasal-Durezol mix-up illustrates how dangerous product problems persist long after recognition. ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011
ISMP Canada. Drug Name Alert: Potential for Confusion between Pradax and Plavix.
ISMP Canada Safety Bulletin 2011; 11(4): 1-2 May 27, 2011