New US labelling to eliminate drug conFUSION
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* Patrick Sullivan

A new program in the US is using upper- and lower-case letters, italics and a mix of colours to highlight drug names in an attempt to reduce the number of medication errors caused by look-alike, sound-alike drug names.

The Food and Drug Administration says about 200 000 Americans are harmed each year because they receive the wrong drug. It cites the confusion surrounding Lamictal (anti-epilepsy) and Lamisal (antifungal) as an example. Under the FDA's new system, the “ictal” portion of Lamictal will appear in red, italicized letters. To reduce confusion between chlorproPAMIDE (antidiabetic) and chlorproMAZINE (tranquilizer), the last 6 letters of both will be captialized.

The FDA is also having employees write test prescriptions before new drugs enter the market in order to test new names. Volunteer nurses and pharmacists then try to decipher them. One-third of the new names have been sent back to the manufacturer for refinement since the testing began.

Spokesperson Ryan Baker says a Health Canada working group is looking at the issue, and the department is also leading a coalition that is examining the broader subject of adverse medical events. In the area of look-alike, sound-alike names, he said Schering Canada Inc. agreed in December to remove Peg-Intron from the market because it sounded similar to a new Schering product, Pegetron. Both are used to treat patients with chronic hepatitis C infection. — *Patrick Sullivan*, *CMAJ*