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.

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	ACTIVASE
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.