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Patient safety in medication nomenclature: orthographic and semantic properties of international nonproprietary names

Rachel Bryan, Jeffrey Aronson, Pius ten Hacken, Alison Williams, Sue Jordan Orcid Logo

Plos One

Swansea University Authors: Rachel Bryan, Sue Jordan Orcid Logo

DOI (Published version): 10.1371/journal.pone.0145431

Abstract

BackgroundConfusion 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’ l...

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Published in: Plos One
Published: 2015
URI: https://cronfa.swan.ac.uk/Record/cronfa25055
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fullrecord <?xml version="1.0"?><rfc1807><datestamp>2020-10-22T15:06:47.3140800</datestamp><bib-version>v2</bib-version><id>25055</id><entry>2015-12-14</entry><title>Patient safety in medication nomenclature: orthographic and semantic properties of international nonproprietary names</title><swanseaauthors><author><sid>7dd77aca51e3e861bc4d4db44f02d38e</sid><firstname>Rachel</firstname><surname>Bryan</surname><name>Rachel Bryan</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>24ce9db29b4bde1af4e83b388aae0ea1</sid><ORCID>0000-0002-5691-2987</ORCID><firstname>Sue</firstname><surname>Jordan</surname><name>Sue Jordan</name><active>true</active><ethesisStudent>false</ethesisStudent></author></swanseaauthors><date>2015-12-14</date><deptcode>SGE</deptcode><abstract>BackgroundConfusion 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 &#x2018;Tall Man&#x2019; 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 FindingsWe 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 (&lt;5 LED), and thus have greater potential for confusion.ConclusionsWe 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.</abstract><type>Journal Article</type><journal>Plos One</journal><publisher/><keywords/><publishedDay>23</publishedDay><publishedMonth>12</publishedMonth><publishedYear>2015</publishedYear><publishedDate>2015-12-23</publishedDate><doi>10.1371/journal.pone.0145431</doi><url/><notes/><college>COLLEGE NANME</college><department>Geography</department><CollegeCode>COLLEGE CODE</CollegeCode><DepartmentCode>SGE</DepartmentCode><institution>Swansea University</institution><degreesponsorsfunders>Swansea University, due to previous AHRC Master's funding to Rachel Bryan</degreesponsorsfunders><apcterm/><lastEdited>2020-10-22T15:06:47.3140800</lastEdited><Created>2015-12-14T21:35:11.2656504</Created><path><level id="1">Faculty of Medicine, Health and Life Sciences</level><level id="2">School of Health and Social Care - Nursing</level></path><authors><author><firstname>Rachel</firstname><surname>Bryan</surname><order>1</order></author><author><firstname>Jeffrey</firstname><surname>Aronson</surname><order>2</order></author><author><firstname>Pius ten</firstname><surname>Hacken</surname><order>3</order></author><author><firstname>Alison</firstname><surname>Williams</surname><order>4</order></author><author><firstname>Sue</firstname><surname>Jordan</surname><orcid>0000-0002-5691-2987</orcid><order>5</order></author></authors><documents><document><filename>0025055-19012016221358.pdf</filename><originalFilename>Bryanetal2015.pdf</originalFilename><uploaded>2016-01-19T22:13:58.1870000</uploaded><type>Output</type><contentLength>875415</contentLength><contentType>application/pdf</contentType><version>Version of Record</version><cronfaStatus>true</cronfaStatus><embargoDate>2016-01-19T00:00:00.0000000</embargoDate><copyrightCorrect>false</copyrightCorrect></document></documents><OutputDurs/></rfc1807>
spelling 2020-10-22T15:06:47.3140800 v2 25055 2015-12-14 Patient safety in medication nomenclature: orthographic and semantic properties of international nonproprietary names 7dd77aca51e3e861bc4d4db44f02d38e Rachel Bryan Rachel Bryan true false 24ce9db29b4bde1af4e83b388aae0ea1 0000-0002-5691-2987 Sue Jordan Sue Jordan true false 2015-12-14 SGE BackgroundConfusion 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 FindingsWe 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.ConclusionsWe 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. Journal Article Plos One 23 12 2015 2015-12-23 10.1371/journal.pone.0145431 COLLEGE NANME Geography COLLEGE CODE SGE Swansea University Swansea University, due to previous AHRC Master's funding to Rachel Bryan 2020-10-22T15:06:47.3140800 2015-12-14T21:35:11.2656504 Faculty of Medicine, Health and Life Sciences School of Health and Social Care - Nursing Rachel Bryan 1 Jeffrey Aronson 2 Pius ten Hacken 3 Alison Williams 4 Sue Jordan 0000-0002-5691-2987 5 0025055-19012016221358.pdf Bryanetal2015.pdf 2016-01-19T22:13:58.1870000 Output 875415 application/pdf Version of Record true 2016-01-19T00:00:00.0000000 false
title Patient safety in medication nomenclature: orthographic and semantic properties of international nonproprietary names
spellingShingle Patient safety in medication nomenclature: orthographic and semantic properties of international nonproprietary names
Rachel Bryan
Sue Jordan
title_short 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_sort Patient safety in medication nomenclature: orthographic and semantic properties of international nonproprietary names
author_id_str_mv 7dd77aca51e3e861bc4d4db44f02d38e
24ce9db29b4bde1af4e83b388aae0ea1
author_id_fullname_str_mv 7dd77aca51e3e861bc4d4db44f02d38e_***_Rachel Bryan
24ce9db29b4bde1af4e83b388aae0ea1_***_Sue Jordan
author Rachel Bryan
Sue Jordan
author2 Rachel Bryan
Jeffrey Aronson
Pius ten Hacken
Alison Williams
Sue Jordan
format Journal article
container_title Plos One
publishDate 2015
institution Swansea University
doi_str_mv 10.1371/journal.pone.0145431
college_str Faculty of Medicine, Health and Life Sciences
hierarchytype
hierarchy_top_id facultyofmedicinehealthandlifesciences
hierarchy_top_title Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id facultyofmedicinehealthandlifesciences
hierarchy_parent_title Faculty of Medicine, Health and Life Sciences
department_str School of Health and Social Care - Nursing{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}School of Health and Social Care - Nursing
document_store_str 1
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description BackgroundConfusion 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 FindingsWe 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.ConclusionsWe 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.
published_date 2015-12-23T03:29:47Z
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