ISMP Calls for Standardization of Drug Names to Prevent Selection Errors

The Institute for Safe Medication Practices (ISMP) is issuing a call to action regarding the need to standardize drug names in order to prevent selection errors. ECRI has the news.

ISMP has recommended entering, “at a minimum, the first five letter characters of a drug name…during searches in automated dispensing cabinets. … Use of only the first two to four characters of the drug name, abbreviations, or a combination of the first few characters and dose has led to the presentation of similar-looking drug names on the screen and has resulted in selection errors.” However, they also acknowledge that this is not the one-size-fits-all approach that may be needed.

A study published in February 2024 revealed that “medication name overlap varies widely.” While some medication names overlap only by a few initial characters, others overlap by seven or more, and can vary from 4 to 29 characters. This study provides insight into the value of “keystroke disambiguation, a type of incremental search mechanism that uses each new keystroke to uniquely identify a single name of interest.” Medication names also may vary by organization or computer system, and the researchers “recommend a standard list of medication names for computer systems.”

ISMP recommends “a more comprehensive approach” to mitigate risks of drug selection errors. For vendors, they suggest supporting “a dynamic search function” and “standard medication names.” They also suggest that organizations “require indications for certain override medications,” “analyze workflow,” “use simulation to educate staff,” “establish a feedback mechanism,” “standardize medication names used in medication systems,” and “stay informed about vendor updates.”