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research-article2013
AOPXXX10.1177/1060028013510150Annals of PharmacotherapyMcDougall et al
Letter
Medication Nonadherence due to
Misunderstanding of the Salt Form
TO THE EDITOR: Medication errors based on their naming continues to be a problem. According to the US
Pharmacopeia/Institute for Safe Medication Practices (USP/
ISMP) Medication Error Reporting Program, at least one
fourth of errors reported involve look-alike and sound-alike
medication names.1 It has also been estimated that 10 000
patient injuries occur in the United States annually because
of patient, provider, and pharmacist confusion over medication names.1 Typical naming errors include, but are not limited to, orthographic similarity (eg, hydroxyzine vs
hydralazine), phonetic similarity (eg, Zantac vs Zyrtec), and
simple differences between letters and numbers (capital letter “I” vs the number 1 in some fonts).2 We have encountered a different type of medication error that was directly
related to patient misunderstanding of the salt form for a
medication. We report 2 such cases.
An 85-year-old woman presented for a follow-up
appointment regarding hypertension and diabetes with her
primary care provider. At a recent appointment, the patient
was prescribed lorsartan for hypertension and her physician
provided her with a medication sample. The labeling on the
prescription sample container listed the medication as losartan potassium. The patient felt that she did not need potassium supplementation so she did not take the medication
regularly. Unfortunately, the patient did not understand the
difference between potassium supplements and potassium
as a salt for an active medication. At the follow-up appointment, her blood pressure was 160/68 mm Hg.
In a second case, an 80-year-old woman presented for a
follow-up appointment regarding hypertension. At this
appointment, the patient stated she was confused by her
medication regimen. She had been prescribed both benazepril 20 mg once daily and hydrochlorothiazide 25 mg once
daily. However, her benazepril prescription label read
“benazepril HCl 20 mg,” and she incorrectly thought she
was receiving a combination tablet of her 2 antihypertensive medications. Therefore, on her own accord she discontinued her hydrochlorothiazide.
In these 2 specific cases, patient confusion resulted from
the salt name appearing in combination with the active
medication on a prescription label or sample packaging.
This led to nonadherence with the prescribed therapy. There
would appear to be a large potential for these types of medication errors as it has been estimated that 50% of medications are administered as salts.1
Health care practitioners, including pharmacists, often
overlook explaining that medications may have an
Annals of Pharmacotherapy
2014, Vol. 48(1) 149­–150
© The Author(s) 2013
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DOI: 10.1177/1060028013510150
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accompanying salt that has no active role in treatment.
While there have been numerous reports involving namerelated errors and their prevention, little information to date
has been published regarding patient confusion that can
arise from salts appearing in the medication name. The
cases presented illustrate two scenarios that could occur frequently without a health care provider’s knowledge.
These problems most likely arise for two main reasons.
First, there is a lack of consistency in whether pharmacies
include the salt form of a medication on the prescription
label. Some pharmacies print the salt name on prescription
bottles and monographs, while others omit it. Guidelines
and regulations on this matter are scarce. In 2009, the Health
Literacy and Prescription Container Labeling Advisory
Panel presented recommendations to the Safe Medication
Use Expert Committee.3 Then, the committee requested
USP to develop recommendations for labels and instructions for patient use. As it relates to medication naming, the
USP recommendation states the label should contain the
“drug name (spell out full generic and brand name) and
strength.”3 Currently, the Iowa Board of Pharmacy has no
rules or regulations regarding the inclusion of the salt form
on prescription medication labels or on monographs for
patients.4
Second is the lack of patient education in this area. The
small amount of time the health care provider has with the
patient is often spent counseling patients on side effects and
directions for use rather than the technicality of the medication name. Pharmacists are at the frontline of educating
patient’s about their medications, including their names. If
salt forms are printed on labels, the pharmacist should consider alerting the patient about the salt. Simply informing
them the ingredient is present in the medication should be
sufficient to avoid most patient misunderstanding. This can
also present the patient with an opportunity to ask questions
regarding the medication name. Patient misinterpretation of
prescription salt formulations may be minimized both by
standardizing the way medication names appear on prescription labeling and also through improved patient education regarding medication names.
Dana J. McDougall, PharmD, BCPS
Meyer Pharmacy, Waverly, IA, USA
Tamara S. Lallier, PharmD, MBA
James D. Hoehns, PharmD, BCPS, FCCP
Northeast Iowa Medical Education Foundation, Waterloo,
IA, USA
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150
Annals of Pharmacotherapy 48(1)
University of Iowa College of Pharmacy,
Iowa City, IA, USA
Robert L. Friedman, MD
Northeast Iowa Medical Education
Foundation, Waterloo, IA, USA
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
References
1. Hoffman JM, Proulx SM. Medication errors caused by confusion of drug names. Drug Saf. 2003;26:445-452.
2. Gabriele S. The role of typography in differentiating lookalike/sound-alike drug names. Healthc Q. 2006;9:88-95.
3.The US Pharmacopeia. Chapter 17: Prescription container
labeling. Pharmacopeial Forum. 2011;37(1).
4. The Iowa Legislature. Iowa Administrative Code. Pharmacy Board
[657]: Chapter 6 General Pharmacy Practice. https://www.legis.
iowa.gov/IowaLaw/AdminCode/ruleDocs.aspx?pubDate=0724-2013&agency=657&chapter=6. Updated July 23, 2013.
Accessed August 5, 2013.
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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