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Look-Alike and
B Sound-Alike Drug Names
Medication Name
Look- or Sound-Alike Name
camphorated tincture of opium (paregoric) Appendix B Look-Alike and Sound-Alike Drug Names | 387
Medication Name
Look- or Sound-Alike Name
388 | Appendices
Medication Name
Look- or Sound-Alike Name
This list of confused drug names is based on information reported in the ISMP Medication Safety Alert! AcuteCare Edition, published by the Institute for Safe Medication Practices (www.ismp.org). This master is used with permission of ISMP. Refer to the ISMP Web site for a more comprehensive list.
Recommendations for Preventing Dispensing Errors
Although manufacturers have an obligation to review new trademarks for error poten-tial before use, there are some things that prescribers, pharmacists, and pharmacy tech-nicians can do to help prevent errors with products that have look- or sound-alike names. The following recommendations are designed to prevent dispensing errors and are based on recommendations from the Institute for Safe Medication Practices (ISMP). As new drugs come to market each year, the list of recognized look-alike, sound-alike drug names grows. For a complete and current listing of look-alike, sound-alike medica-tions, please go to the ISMP Web site and search for that list.
• 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 prod-
uct’s indication on all outpatient prescriptions and on inpatient prn orders. With
name pairs known to be problematic, reduce the potential for confusion by writ-
ing 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.
Appendix B Look-Alike and Sound-Alike Drug Names | 389
• Accept verbal or telephone orders only when truly necessary. Require staff to
read back all orders, spell product names, and state their indication. Like medica-tion names, numbers can sound alike, so staff should read the dosage back in numerals (e.g., “one five” for 15 mg) 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 boldface, 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 audi-tory 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 that 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, tech-
nicians, unit secretaries, and physicians to view the samples of the written prod-
uct name, as well as to pronounce it, to determine whether 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, then 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 priori-ties for error reduction. Also maintain awareness of problematic product names and error prevention recommendations provided by the 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 medi-
cation errors. Stay current with alerts from the ISMP, FDA, and USP in case new
problematic name pairs emerge. Note that many sound-alike medications are
indeed the same medication but in a different dosage form or drug delivery
system (i.e., Metformin, Metformin XL).

Source: http://irc.emcp.com/ircfiles/PharmEssentials/Appendices/AppendixB.pdf