by Michael R. Cohen, R.Ph.
All too often, when we learn about the death of someone whose name we might recognize, we do not really know what they have accomplished in their lifetime. Many of us at the Institute for Safe Medication Practices have had the opportunity to interact with George Di Domizio, who passed away last Friday after a 5-year battle with esophageal cancer. George was a vibrant force in the pharmaceutical industry, who played a critical role in the history of our organization. I’d like to provide a little insight about this man, who was—hands down—our most important industry advocate for safe medication practices and patient safety.
I met George during the late 1980s when he was in charge of naming drugs at Merck as the director of creative development. Among his drug-naming achievements are Pepcid, Zocor, and Bextra to name a few. In the 1980s neither the Pharmaceutical Research and Manufacturers of America (PhRMA) industry nor the U.S. Food and Drug Administration (FDA) was mindful of the need for proactive measures to prevent medication errors from look-alike and sound-alike drug names, which accounted for about a quarter of all medication errors overall. Names were chosen for their “striking power” with physicians—a term used to sum up how well doctors would remember the name so they’d be more apt to prescribe it—and how easily the name rolled off the tongue. No safety testing of drug names was done to identify currently available product names with which a new name might be confused. If errors happened after product launch, it was standard in the industry to blame doctors for their poor handwriting or pharmacists for being careless in not reading the prescription correctly. Injuries and even fatalities from medication errors were not uncommon.
Merck had a co-marketing agreement with the Swedish company Astra that owned the rights to an ulcer drug called Losec (omeprazole). I had been publishing a monthly column on medication errors in the journal Hospital Pharmacy, where readers were invited to submit reports of medication errors they’d experienced in their practice. Soon after launch it became clear that the drug was on its way to blockbuster status. But there was a problem. We began to receive reports of very serious medication errors in which prescriptions written for Losec 20 mg were confused with Lasix (furosemide) 20 mg. A patient who suffered a bleeding ulcer got Lasix, a diuretic or “water pill” and bled to death. A heart patient who needed Lasix to treat fluid retention got the ulcer drug and died from a worsening of their congestive heart failure.
Because of the serious nature of these mix-ups, journal editor of Hospital Pharmacy, Neil Davis, and I immediately passed this information on to Merck and the FDA, and I published alerts about the problem in journal columns, requesting action by the company and federal agency. At first, corporate leadership at Merck balked at the idea of doing anything at all. But George knew this was a problem that wasn’t going to go away. He maintained contact with us as he steadfastly argued for action by Merck as more and more reports of errors came in.
The company eventually sponsored a 1989 ad campaign directed at pharmacists to educate them about the potential for misreading Losec orders as Lasix or vice versa. But the ads frustrated pharmacists because they felt the company was blaming them for misreading prescriptions when, in fact, a root cause of mix-ups with Lasix was the look-alike name Losec. George received criticism about the ad from Neil and I, and many letters from pharmacists. Because this was an important safety issue, George continued to champion the idea of a name change, pushing it all the way up to the Merck Board of Directors through their vice chairman, John Lyons.
Despite much controversy and hesitation by Astra and Merck leadership and some board members, the decision was made by Lyons to change the name of Losec. At that point, George engaged Neil and me to line up healthcare practitioners to identify if any of several proposed names might be confused with anything else on the market. One of the names, Prilosec, which was developed by George, eventually won out. Along with the name change came an end to the problem. It is interesting to note that omeprazole is available throughout the world and still known as Losec even though many countries also have Lasix. Thus, we occasionally learn of a fatal mix-up outside the U.S. But to this day, the U.S. is the only country where the name was changed to eliminate the risk of mix-ups with Lasix.
A great deal of learning came from this, and George began to work with trademark colleagues outside of Merck to design methods for safety testing of drug names and advocate for such processes as a way to avoid look-alike and sound-alike medication errors. The basic practices he helped develop are now standard throughout the PhRMA industry and considered mandatory when a new drug application is submitted to FDA.
George eventually left Merck and began his own consulting business, Gemini Trademarks, where he worked with many different companies to create safe names for their new products, always including name testing as part of the process. He also found time to pitch in to help ISMP, serving as a trustee and advisor, smoothing the way as we sought to interact with industry and government authorities. He was instrumental in helping us secure our first substantial grant, which enabled us to hire our first employee, perform research into the most common drugs involved in serious errors, and establish our current acute care newsletter, the ISMP Medication Safety Alert!. To those of us at ISMP, George’s legacy exists in all the harm and suffering he has helped to prevent.
As noted in his obituary, George always maintained a win-win attitude and positive outlook, perpetually looking at the positive side of life in whatever he did or planned to do. No matter what the circumstance, George would always find something good to say about a situation or an individual. A few weeks back he mentioned to me that he’d accepted that he was on a down curve. Still, as always, there was good news: it was nearly 5 years since he was first diagnosed with cancer and he was still alive. Experts say that if you are still alive after 5 years with cancer, you’re cured. So to George’s way of thinking, maybe he was going to die from the cancer, but the good news was, he was still cured!
George had a habit that I had come to appreciate after every meeting we had attended and every educational seminar we presented at PhRMA, FDA, or any other group. As we were traveling back home, he would always take time to rate the session numerically from 1-10, with 10 being best. I don’t believe I ever once heard him rate anything lower than, “I’d give that a nine.” I know I speak for many of us when I say how much he will be missed. George, you were always a 10!
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