For example, giving a client Ropinirole (for Parkinsons) rather than Risperidone (for schizophrenia) could result in a patient suffering a mental health breakdown. The FDA received reports of that error occurring 226 times. The two drugs had similar labels and were prescribed in the same dose and frequency so pharmacists and pharmacy technicians had a hard time telling them apart.

In the case of those two drugs, the FDA asked the pharmaceutical company to change the packaging and lettering to better distinguish the drugs. In some cases, the FDA proactively asks a drug company to come up with a different name for a new drug because it's too similar to something already on the market. Or, less commonly, it may require a company to change the name of a drug after it has already been released because too many medication errors are being reported.

But this summer, the drug companies are complaining that the FDA name review process is "burdensome and disruptive" to business. They want it repealed. The ISMP does not. While acknowledging the process is less than perfect, they say it plays a crucial role in improving patient safety.

While careful oversight of one's medical treatment is always a good practice for patients, there is little consumers can do to protect themselves from a drug mixup that may occur at the pharmacy. Preventing medication errors must be done at the level of the pharmacy or the drug company.

Source: NPR, "What's in a drug name? Sometimes, enough to cause mix-ups," by Eliza Barclay, August 17, 2011.