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College Resource Center : Health Careers : Readings in Subject Area : Drug Name Safety

Drug Name Safety

While manufacturers have an obligation to review new trademarks for error potential before use, there are some things that prescribers, pharmacists, and pharmacy technicians can do to help prevent errors with products that have look- or sound-alike names. The Institute for Safe Medication Practices (ISMP) (www.ismp.org) has provided following recommendations designed to prevent dispensing errors.

  • Use electronic prescribing to prevent confusion with handwritten drug names.
  • Encourage physicians to write prescriptions that clearly specify the dosage form, drug strength, and complete directions. They should include the product’s indication on all outpatient prescriptions and on inpatient prn orders. With name pairs known to be problematic, reduce the potential for confusion by writing prescriptions using both the brand and generic name. Listing both names on medication administration records and automated dispensing cabinet computer screens also may be helpful.
  • Whenever possible, determine the purpose of the medication before dispensing or administering it. Many products with look-alike or sound-alike names are used for different purposes.
  • Accept verbal or telephone orders only when truly necessary. Require staff to read back all orders, spell the product name, and state its indication. Like medication names, numbers can sound alike, so staff should read the dosage back in numerals (ex. “one five” for fifteen milligrams) to ensure clear interpretation of dose.
  • When feasible, use magnifying lenses and copyholders under good lighting to keep prescriptions and orders at eye level during transcription to improve the likelihood of proper interpretation of look-alike product names.
  • Change the appearance of look-alike product names on computer screens, pharmacy and nursing unit shelf labels, and bins (including automated dispensing cabinets), pharmacy product labels, and medication administration records by highlighting, through bold face, color, and/or tall man letters, the parts of the names that are different (e.g., hydrOXYzine, hydrALAzine).
  • Install a computerized reminder (also placed on automated dispensing cabinet screens) for the most serious confusing name pairs so that an alert is generated when entering prescriptions for either drug. If possible, make the reminder auditory as well as visual.
  • Affix “name alert” stickers in areas where look-alike or sound-alike products are stored (available from pharmacy label manufacturers).
  • Store products with look-alike or sound-alike names in different locations. Avoid storing both products in the fast-mover area. Use a shelf sticker to help locate the product that is moved.
  • Continue to employ an independent check in the dispensing process (one person interprets and enters the prescription into the computer and another reviews the printed label against the original prescription and the product).
  • Open the prescription bottle or the unit dose package in front of the patient to confirm the expected product appearance and review the indication. Caution patients about error potential when taking products that have a look-alike or sound-alike counterpart. Take the time to fully investigate the situation if a patient states he or she is taking an unknown medication.
  • Monitor reported errors caused by look-alike and sound-alike medication names and alert staff to mistakes.
  • Look for the possibility of name confusion when a new product is added to the formulary. Have a few clinicians handwrite the product name and directions, as they would appear in a typical order. Ask frontline nurses, pharmacists, technicians, unit secretaries, and physicians to view the samples of the written product name as well as pronounce it to determine if it looks or sounds like any other drug product or medical term. It may be helpful to have clinicians first look at the scripted product name to determine how they would interpret it before the actual product name is provided to them for pronunciation. Once the product name is known, clinicians may be less likely to see more familiar product names in the written samples. If the potential for confusion with other products is identified, take steps to avoid errors as listed below.
  • Encourage reporting of errors and potentially hazardous conditions with look-alike and sound-alike product names and use the information to establish priorities for error reduction. Also maintain awareness of problematic product names and error prevention recommendations provided by ISMP (www.ismp.org and also listed on the quarterly Action Agenda), FDA (www.fda.gov), and USP (www.usp.org).
  • Review Table B.1 for look-alike and sound-alike drug name pairs in use at your practice location. Decide what actions might be warranted to prevent medication errors. Stay current with alerts from ISMP, FDA, and USP in case new problematic name pairs emerge.
Table B.1 Look-Alike and Sound-Alike Medications
Abelcet amphotericin B  
Accupril Aciphex  
acetazolamide acetohexamide  
acetohexamide acetazolamide  
Aciphex Aricept  
Aciphex Accupril  
Activase TNKase  
Actonel Actos  
Actos Actonel  
Adderall Inderal  
Advicor Altocor  
AGGRASTAT argatroban  
Aldara Alora  
Alkeran Leukeran Myleran
Allegra Viagra  
Alora Aldara  
Altocor Advicor  
Amaryl Reminyl  
AmBisome amphotericin B  
amphotericin B Abelcet  
amphotericin B Ambisome  
antacid Atacand  
Antivert Axert  
Anzemet Avandamet  
argatroban Aggrastat  
Aricept Aciphex  
aripiprazole Proton Pump Inhibitors  
aripiprazole rabeprazole  
Asacol Os-Cal  
Atacand antacid  
Atrovent Natru-Vent  
Avandamet Anzemet  
Avandia Prandin  
Avandia Coumadin  
Avinza Invanz  
Avinza Evista  
Axert Antivert  
BayHep B BayRab BayRho-D
BayRab BayRho-D BayHep B
BayRho-D BayHep B BayRab
Bicillin C-R Bicillin L-A  
Bicillin L-A Bicillin C-R  
Brethine Methergine  
camphorated tincture of opium (paregoric) opium tincture  
carboplatin cisplatin  
Cedax Cidex  
Celexa Zyprexa  
chlorpromazine chlorpropamide  
chlorpropamide chlorpromazine  
Cidex Cedax  
cisplatin carboplatin  
Claritin-D Claritin-D 24  
Claritin-D 24 Claritin-D  
Clozaril Colazal  
Colace Cozaar  
Colazal Clozaril  
colchicine Cortrosyn  
Comvax Recombivax HB  
Cortrosyn colchicine  
Coumadin Avandia  
Cozaar Colace  
Cozaar Zocor  
dactinomycin daptomycin  
daptomycin dactinomycin  
Darvon Diovan  
daunorubicin idarubicin  
Denavir Indinavir  
Depakote Depakote ER  
Depakote ER Depakote  
Depo-Medrol Solu-Medrol  
Diabenese Diamox  
DiaBeta Zebeta  
Diamox Diabenese  
Diatex (diazepam in Mexico) Diatx  
Diatx Diatex (diazepam in Mexico)  
Dilacor XR Pilocar  
Dilaudid Dilaudid-5  
Dilaudid-5 Dilaudid  
Dioval Diovan  
Diovan Dioval  
Diovan Zyban  
Diovan Darvon  
Diprivan Ditropan  
Ditropan Diprivan  
dobutamine dopamine  
dopamine dobutamine  
doxorubicin hydrochloride liposomal doxorubicin (DOXIL)  
Duricef Ultracet  
Enbrel Levbid  
Endocet Indocid  
Engerix-B adult Engerix-B pediatric/adolescent  
Engerix-B pediatric/adolescent Engerix-B adult  
ephedrine epinephrine  
epinephrine ephedrine  
Estratest Estratest H.S.  
Estratest H.S. Estratest  
ethambutol Ethmozine  
Ethmozine ethambutol  
Evista Avinza  
Femara Femhrt  
Femhrt Femara  
fentanyl sufentanil  
folic acid folinic acid (leucovorin calcium)  
folinic acid (leucovorin calcium) folic acid  
Foradil Toradol  
gentamicin gentian violet  
gentian violet gentamicin  
Granulex Regranex  
Healon Hyalgan  
heparin Hespan  
Hespan heparin  
Humalog Humulin  
Humalog Mix 75/25 Humulin 70/30  
Humulin Humalog  
Humulin 70/30 Humalog Mix 75/25  
Hyalgan Healon  
hydromorphone morphine  
idarubicin daunorubicin  
Inderal Adderall  
indinavir Denavir  
Indocid Endocet  
infliximab rituximab  
Invanz Avinza  
iodine Lodine  
ISORDIL Plendil  
isotretinoin tretinoin  
K-Phos Neutral Neutra-Phos K  
Kaletra Keppra  
Keppra Kaletra  
KETALAR ketorolac  
ketorolac KETALAR  
Lamictal Lamisil  
Lamisil Lamictal  
lamivudine lamotrigine  
lamotrigine lamivudine  
Lanoxin levothyroxine  
Lantus Lente  
Lasix Luvox  
Lente Lantus  
leucovorin calcium Leukeran  
Leukeran Myleran Alkeran
Levbid Enbrel  
levothyroxine Lanoxin  
Lexapro Loxitane  
Lipitor Zyrtec  
liposomal doxorubicin (DOXIL) doxorubicin hydrochloride  
Lodine iodine  
Lotronex Protonix  
Loxitane Lexapro  
Lupron Depot-3 Month Lupron Depot-Ped  
Lupron Depot-Ped Lupron Depot-3 Month  
Luvox Lasix  
Maxzide Microzide  
Metadate methadone  
Metadate CD Metadate ER  
Metadate ER Metadate CD  
Metadate ER methadone  
methadone Metadate ER  
methadone Metadate  
Methergine Brethine  
Micronase Microzide  
Microzide Maxzide  
Microzide Micronase  
mifepristone misoprostol  
Miralax Mirapex  
Mirapex Miralax  
misoprostol mifepristone  
morphine hydromorphone  
morphine, oral liquid concentrate morphine, non-concentrated oral liquid  
MS Contin OxyContin  
Mucinex Mucomyst  
Mucomyst Mucinex  
Myleran Alkeran Leukeran
Narcan Norcuron  
Natru-Vent Atrovent  
Navane Norvasc  
Neulasta Neumega  
Neumega Neupogen  
Neumega Neulasta  
Neupogen Neumega  
Neurontin Noroxin  
Neutra-Phos K K-Phos Neutral  
Norcuron Narcan  
Noroxin Neurontin  
Norvasc Navane  
Novolin 70/30 NovoLog Mix 70/30  
NovoLog Mix 70/30 Novolin 70/30  
Occlusal-HP Ocuflox  
Ocuflox Occlusal-Hp  
opium tincture camphorated tincture of opium (paregoric)  
Os-Cal Asacol  
oxycodone OxyContin  
OxyContin MS Contin  
OxyContin oxycodone  
Pamelor Panlor DC  
Panlor DC Pamelor  
Patanol Platinol  
Paxil Taxol  
Paxil Plavix  
Percocet Procet  
Pilocar Dilacor XR  
Platinol Patanol  
Plavix Paxil  
Plendil Isordil  
pneumococcal 7-valent vaccine pneumococcal polyvalent vaccine  
pneumococcal polyvalent vaccine pneumococcal 7-valent vaccine  
Prandin Avandia  
Precare Precose  
Precose Precare  
Prilosec Prozac  
probenecid Procanbid  
Procanbid Probenecid  
Procardia XL Protain XL  
Procet Percocet  
propylthiouracil Purinethol  
Protain XL Procardia XL  
protamine Protonix  
Proton Pump Inhibitors aripiprazole  
Protonix Lotronex  
Protonix protamine  
Prozac Prilosec  
Purinethol propylthiouracil  
quinine quinidine  
quinidine quinine  
rabeprazole aripiprazole  
Recombivax HB Comvax  
Regranex Granulex  
Reminyl Robinul  
Reminyl Amaryl  
Retrovir ritonavir  
Rifater RIFIDIN  
Rifidin RIFATER  
Ritalin ritodrine  
Ritalin LA Ritalin-SR  
Ritalin-SR Ritalin LA  
ritodrine Ritalin  
ritonavir Retrovir  
rituximab infliximab  
Robinul Reminyl  
Roxanol Roxicodone Intensol  
Roxanol Roxicet  
Roxicet Roxanol  
Roxicodone Intensol Roxanol  
saquinavir (free base) saquinavir mesylate  
saquinavir mesylate saquinavir (free base)  
Saquinivir Sinequan  
Sarafem Serophene  
Serophene Sarafem  
Seroquel Serzone  
sertraline Soriatane  
Serzone Seroquel  
Sinequan Saquinivir  
Solu-Medrol Depo-Medrol  
Soriatane sertraline  
sufentanil fentanyl  
sumatriptan zolmitriptan  
Taxol Taxotere  
Taxol Paxil  
Taxotere Taxol  
Tegretol Tequin  
Tegretol Tegretol XR  
Tegretol XR Tegretol  
Tequin Tegretol  
Tequin Ticlid  
Testoderm Testoderm w/ Adhesive  
Testoderm w/ Adhesive Testoderm  
tetanus diptheria toxoid (Td) tuberculin purified protein derivative (PPD)  
tiagabine tizanidine  
Tiazac Ziac  
Ticlid Tequin  
tizanidine tiagabine  
TNKase t-PA  
Tobradex Tobrex  
Tobrex TobraDex  
Topamax Toprol-XL  
Toprol-XL Topamax  
Toradol Foradil  
t-PA TNKase  
Tracleer TriCor  
tramadol hydrochloride trazodone hydrochloride  
trazodone hydrochloride tramadol hydrochloride  
tretinoin isotretinoin  
TriCor Tracleer  
tuberculin purified protein derivative (PPD) tetanus diptheria toxoid (Td)  
Tylenol Tylenol PM  
Tylenol PM Tylenol  
Ultracet Duricef  
valacyclovir valganciclovir  
Valcyte Valtrex  
valganciclovir valacyclovir  
Valtrex Valcyte  
Varivax VZIG  
Vexol VSol  
Viagra Allegra  
vinblastine vincristine  
vincristine vinblastine  
Viokase Viokase 8  
Viokase 8 Viokase  
Viracept Viramune  
Viramune Viracept  
VSol Vexol  
VZIG Varivax  
Wellbutrin SR Wellbutrin XL  
Wellbutrin XL Wellbutrin SR  
Xeloda Xenical  
Xenical Xeloda  
Zantac Zyrtec  
Zebeta DiaBeta  
Zebeta Zetia  
Zestril Zetia  
Zetia Zebeta  
Zetia Zestril  
Ziac Tiazac  
Zocor Cozaar  
zolmitriptan sumatriptan  
Zostrix Zovirax  
Zovirax Zyvox  
Zovirax Zostrix  
Zyban Diovan  
Zyprexa Zyrtec  
Zyprexa Celexa  
Zyrtec Zyprexa  
Zyrtec Zantac  
Zyrtec Lipitor  
Zyvox Zovirax  

Source: The information in this appendix was reported in the ISMP Medication Safety Alert! Acute Care Edition, January 1996-September 2004. © 2005 Institute for Safe Medication Practices. This material is used with permission of ISMP.

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