title: Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names.
abstract: BACKGROUND
  Confusion 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.
  
  
  RESULTS
  We 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.
  
  
  CONCLUSIONS
  We 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.
authors.affiliation: Swansea University, Swansea, Wales, United Kingdom.
authors.forename: Rachel
authors.initials: R
authors.lastname: Bryan
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Jeffrey K
authors.initials: JK
authors.lastname: Aronson
authors.affiliation: Institute for Translation Studies, University of Innsbruck, Innsbruck, Austria.
authors.forename: Pius
authors.initials: P
authors.lastname: ten Hacken
authors.affiliation: Swansea University, Swansea, Wales, United Kingdom.
authors.forename: Alison
authors.initials: A
authors.lastname: Williams
authors.affiliation: Swansea University, Swansea, Wales, United Kingdom.
authors.forename: Sue
authors.initials: S
authors.lastname: Jordan
mesh_terms: D004348:Drug Labeling; D006801:Humans; D008037:Linguistics; D008508:Medication Errors / Q000517:prevention & control*; D061214:Patient Safety; D004364:Pharmaceutical Preparations / Q000145:classification*; D012660:Semantics; D009626:Terminology as Topic
chemical_list: D004364:Pharmaceutical Preparations