potential benefit of the medication is judged to outweigh the risk to the patient, such as in the following examples:
An unconscious child who is hypoglycaemic is indicated for glucose 10% administration. The signs used here as indications for the medication are both the finding of hypoglycaemia and the child’s level of consciousness.
A 50‐year‐old male patient who is experiencing crushing left‐sided chest pain has an indication for aspirin administration, provided you have established that he has no abnormal bleeding tendencies.
Sometimes, despite there being an indication for a medication, you will not be able to administer it because of a contraindication. A contraindication is a reason to withhold medication because it might cause harm to the patient, as in the following examples:
Aspirin is contraindicated for analgesia and fever in paediatric patients who are under 16 years of age because of the risk of Reye’s syndrome. The syndrome is quite rare and only occurs in children, but is very serious.
Ipratropium, a bronchodilator commonly used with salbutamol for the treatment of bronchospasm, is usually contraindicated in patients who have glaucoma, as a known side‐effect is an increase in intraocular pressure.
Amiodarone is an antiarrhythmic indicated for tachyarrhythmias (cardiac arrhythmias which involve an increased heart rate), but contraindicated in torsades de pointes, a potentially fatal tachyarrhythmia which can result from long QT syndrome, because amiodarone will result in further protraction of the QT interval.
As data about medications are gathered, indications and contraindications may change, so it is important to remain abreast of these changes in your practice as a paramedic.
Episode of care
You attend a 49‐year‐old male patient complaining of left‐sided central chest pain. He is diaphoretic, pale and short of breath.
You ask him about his medical history. He reports he has a ‘high blood pressure problem’. You glance at his medication list and do not recognise any common antihypertensive medications.
Your check his observations and gain a detailed history, while preparing him for a 12‐lead ECG. The ECG suggests a lateral myocardial infarct. Your provisional diagnosis is acute coronary syndrome and you proceed with administering aspirin and a vasodilator.
En route he rapidly becomes hypotensive with a decreased level of consciousness. At hospital, you discover he has recently commenced on a vasodilator for aggressive management of his pulmonary hypertension. This medication was not on his medication list.
You may see medications that patients are taking for indications other than the listed indications. Vasodilators such as sildenafil (Viagra®) and vardenafil (Levitra®) are often prescribed to males for erectile dysfunction, but can also be used to treat pulmonary hypertension.
Patients may be unsure what they are taking medications for and it is imperative to gain a detailed history prior to administration of any medication to ensure contraindications are not encountered. Medications can be used for purposes other than their primary indication.
Naming and classifying drugs
Every drug will have a number of names. Knowing the correct name of a drug is vital in the prevention of medication errors, and becomes even more important when drugs can be identified by several different names. All drugs will have an individual chemical name which conveys very accurately (at least to a chemist!) the drug’s molecular structure. These names are usually long, difficult to say and impossible to remember, and they are usually left to research chemists. Many drugs can also be known by the name of the chemical class they belong to, such as opioids or benzodiazepines. But it is the generic, or official, name of the drug that health practitioners should always recognise a drug by. This name should be sufficiently different from any other drug name to minimise the risk of any drug being mistaken for another. With a few exceptions, generic names are usually the same regardless of where in the world you are, and they often derive in some way from the name of the chemical class of the drug, which is often convenient as it makes it easy to identify the class a drug belongs to by its generic name. The generic names of drugs belonging to the statin class of drugs, for example, end in ‐statin, with agents such as atorvastatin, rosuvastatin, fluvastatin and simvastatin. Generic names of drugs belonging to the beta‐blocker class end in ‐olol and include propranolol, atenolol, pindolol and nebivolol.
Many drug formulations will also have a trade name given to the particular drug formulation by the company that produced it. These names may relate to the generic name or they may relate more closely to their therapeutic use, but because of the multiple formulations available and multiple companies producing them, the trade names of drugs will vary widely depending on where the drug is sold and what it is sold for. Needless to say, these names are not a reliable way to identify the drugs but unfortunately, they are often the most prominent and eye‐catching name on the packaging, which will mean that patients will usually refer to drugs by the trade name, unless they are receiving a generic version of the drug. To try and reduce confusion, the Australian government, for example, passed a law, effective February 1, 2021, that requires prescribers to write the generic name of the medication first on any prescription, either without a trade name or with the trade name in brackets after it. Combined with requirements for drug manufacturers to make the generic name of the active drug in the medication more prominent on the packaging than the trade name, the aim is to increase awareness of the active ingredients in medications and to reduce confusion.
With the huge range of drugs currently licensed for use, there are often multiple individual drugs available for any particular indication, so it is important that we also classify our drugs to make talking about them easier. We can classify drugs based on their chemical structures, mechanism of action or broader area of therapeutic use. The functional classifications (those relating to what the drugs do or what they are used for) are the most widely used, as they reflect the clinical uses of the drugs, but we often refer to certain groups of drugs by their chemical classification, as usually all agents belonging to a certain chemical class also have a predictable effect on function. Table 1.1 gives some examples of the ways in which drugs are named and categorised.
Look‐alikes and sound‐alikes
Mistaking one medication for another because the two names (either generic or trade names) sound alike or the packages look alike is a common cause of medication error. Errors due to look‐alike sound‐alike (LASA) medications have become so widespread that the World Health Organization launched a worldwide effort to reduce medication errors that come about in this way (WHO, 2007), and many governments have made changes to their medication labelling and naming The addition of ‘tall man’ writing in the name of a drug has been introduced in the UK, Canada, Australia and the US to make the differences between drug names clearer. This technique involves capitalising the parts of the name that are most likely to be misread, for example:
AmiloRIDE, AmlodiPINE, BuPROPion, BupreNORphine.
The mix of capitalised lettering in the name disrupts rapid reading and forces a more careful observation of the name.
The main element in reducing medication errors, however, continues to be careful cross‐checking of LASA medications prior to administration, and ensuring that look‐alike medications are not stored in close proximity to each other. Because the packaging and appearance
