Med-ERRS Spring 2014 Newsletter

Volume 7, Issue 2 UPDATE-ERR Spring 2014

President's Message

Dear Friends and Colleagues:

Spring (and warmer weather) has finally arrived!

Med-ERRS is excited to tell you about a new project we are currently working on.

We know that some medication errors occur when two trademarks are confused due to look-alike and sound-alike similarities between the names. We also generally recognize that in order for an error to occur between two drugs with potentially confusing trademarks, typically there is some overlap in the products' clinical characteristics. Clinical characteristics (or non-name attributes) can include dose, strength, route of administration, storage and indication, among others. We believe that, in general, without at least some clinical overlap, the new proposed trademark would less likely be confused with a similar looking or similar sounding other trademark.

In recent months, Med-ERRS has been made aware that some regulatory authorities are rejecting proposed trademarks citing potential confusion with existing products that have little to no similarity in terms of clinical data overlap. To dig deeper into this topic, we are undertaking a project that evaluates actual name pair errors that have occurred to see what type of correlation exists between the clinical criteria for each product. We are in the process of analyzing a large body of data containing look-alike and sound-alike errors that have been reported through the National Medication Errors Reporting Program (ISMP MERP).

We plan to share our results with our clients and colleagues upon completion of the evaluation. We hope that this evaluation will help to provide relevant data that will ultimately save both the health authorities and our clients some time and resources in the trademark development process.

In the meantime, if you would like to learn more about Med-ERRS and the services we offer, please contact our office directly by calling (215) 947-8306 and ask for Diane Bernstein (Marketing Representative). You may also email us at

Warm regards,


In the News

ISMP Celebrates 20th Anniversary

2014 marks the Institute for Safe Medication Practices (ISMP) 20th anniversary of its official incorporation as a nonprofit organization. Med-ERRS would like to congratulate our parent company on reaching this important milestone and thank them for their years of service in patient safety.

For those who are unfamiliar with ISMP, they are the nation’s only 501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use. ISMP represents nearly 40 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. The organization is known and respected worldwide as an important resource for impartial, timely, and accurate medication safety information.

As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, grants, revenue from educational programs and safety consulting, newsletter subscriptions, and volunteer efforts to pursue its lifesaving work. If you are interested in supporting ISMP, please visit their website by clicking here. You may also call them directly at 215-947-7797.

Photos from 87th PTMG Conference in London

Susan and Diane recently attended the Pharmaceutical Trade Marks Group annual conference in London. To view some photos taken during the meeting, please click here.

Relevant Safety Issues from ISMP's Medication Safety Alert!® Newsletter

Look-alike, sound-alike mix-up: Florinef vs. Floranex

A nurse took a verbal order for lactobacillus tablets but did not know how to enter a lactobacillus order into the hospital's electronic ordering system, so she called the pharmacy. A pharmacist told her to enter the probiotic supplement FLORANEX (lactobacillus). However, she thought she heard a more familiar drug name, FLORINEF (fludrocortisone), and entered that. Fortunately, another pharmacist recognized the error while reviewing the order. In another case, also involving a probiotic supplement, a physician intended to order FLORASTOR (Saccharomyces boulardii lyo) for a patient. This was communicated verbally to a medical resident who entered "flor" into the computer and accidentally selected Florinef. The resident thought Florastor and Florinef were the same product and ordered the default dose built into the order entry system. Luckily, a pharmcist also caught this error.

If you happen to use Floranex or Florastor at your hospital and also list Florinef in your system, be alert to the risk of the mix-up. These names sound almost identical when spoken and can also be confused in print or when handwritten. According to the US Food and Drug Administration (FDA), the brand Florinef has been discontinued, so removing the brand product from your computer system can prevent errors. Lactobacillus should be listed in computer systems and prescribed by its generic name. It's doubtful that the dietary supplement manufacturer would be motivated to change the name of its Floranex product, especially since Florinef is no longer on the market. However, you may consider purchasing a different brand of lactobacillus (e.g. CULTURELLE) to prevent mix-ups. The issue of drug names being confused with dietary supplements in one that bears consideration by FDA's Center for Food Safety and Applied Nutrition (CFSAN), which regulates food supplements, so situations like this can be avoided.

ISMP Medication Safety Alert®, Acute Care: Volume 19, Issue 2

Our Services
  • ERRS MODEL®: Med-ERRS has developed this service for evaluating the safety of trademarks. ERRS MODEL incorporates various techniques recommended by the FDA to proactively help prevent medication errors by testing for potential look-alike and sound-alike confusion with proposed trademarks.
  • EVALUATE-ERR®: A safety consulting service that examines a unique aspect of a product (such as a dosage form, special packaging, or trademark) and its vulnerability to user error.
  • SCREEN-ERR®: Helps companies evaluate multiple pharmaceutical trademark candidates at an early stage in the trademark development process.
  • Package and Label Evaluation: Helps clients create packaging and labels that are easy to understand and consistent with the most current FDA and worldwide regulatory authorities.
  • Safety Consulting: Provides consultative services which are related to a variety of medication safety-related issues.


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