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Patient Safety Solutions
Look-Alike, Sound-Alike Medication Names
CONTENT
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Look-Alike Sound-Alike
(LASA) Medication
Names
Statement of the Problem and Impact
Confused Drug Names
Suggested Actions
Applicability
Opportunities for Patients and Family Involvement
Safety Strategy in Confused Drug Names
Potential Barriers
Conclusion
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Mohamed Nasser
Director, Pharmacy & Drug Control
MOH - Bahrain
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Statement of the Problem
and Impact
Statement of the Problem
and Impact
¾ LASA drug names are a serious problem in health
care, accounting for 29% of medication dispensing
errors. Name confusion is a causative factor in 1525% of all medication errors (Chadwick, 2003 & JACHO,
One of the most common frequent
causes of pharmacy medication
errors is failure to accurately identify
drugs, most prominently due to lookalike and sound-alike drug names
2007).
¾ Medication errors involving LASA drug names mixup can cause serious patient harm. It is often
difficult to detect the error, as the dispensed
medication is presumed to have been prescribed for
the patient (Chadwick, 2003).
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(Leape et al JAMA 1995)
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Statement of the Problem
and Impact
Confused Drug Names
Some common confused drug name pairs
¾ The US FDA rejects approximately one-third of
proposed names for new products. Despite of this,
over 600 pairs of LASA drug names have been
reported in 2003 (MC-PME, 2001 & JACHO, 2003).
•Losec (Omeorazole) and Lasix (Frusemide)
•Avanza (Mirtazapine) and Avandia (Rosiglitazone)
•Celebrex (Celecoxib) and Cerebyx (Fosphenytoin)
•Reminyl (Galantamine) and Amaryl (Glimepiride)
•Diamox (Acetazolamide) and Zimox (Amoxicillin)
•Lamisil (Terbeniafen) and Lamictal (Lamotrigine)
•Taxol (Paclitaxel) and Taxotere (Docetaxel)
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¾ Presence of thousands of drugs with trademarked
(brand) or non-proprietary names increases the
chance for the name confusion.
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Confused Drug Names
How similar is too similar?
Contributing to this confusion are:
• Illegible handwriting
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Incomplete knowledge of drug names
New products
Similar packaging or labeling
Similar clinical uses
Similar strength and dosage forms
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Who would imagine confusion
between these two products ?
Similar when handwritten
Confusion between two “high
alert” medications
Zyrtec or Lipitor ??
Avandia or Coumadin ??
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Suggested Actions
Diovan: 9 Products in the range
¾Maintain awareness of LASA names as published by various
safety agencies and review the LASA list annually.
Diovan® (Valsartan)
¾Clearly specify the dosage form, strength and clear and
complete directions on prescriptions. These variables may
help pharmacy and nursing staff in products differentiation.
40mg, 80mg, 160mg and 320mg
¾With name pairs known to be problematic, reduce the
potential for confusion by writing prescriptions using both
the brand and generic names.
Co-Diovan® (Valsartan + HCTZ)
80/12.5mg, 160/12.5mg, 160/25mg, 320/12.5mg
and 320/25mg
¾With name pairs known to be problematic, include the
purpose of medication on prescriptions. In most cases drugs
that sound or look similar are used for different purposes.
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Suggested Actions
Suggested Actions
¾Use technology to minimize medication errors;
computerized physician order entry (CPOE), bar coding or
automated dispensing devices.
¾Alert patients to the potential for mix-ups, especially
with known problematic drug names. Advise out-patients
to insist on pharmacist counseling when picking up
prescription and to verify that medications match what the
prescribers has told them.
¾In automated prescriptions, install and utilize computerized
alerts to remind providers about potential problems during
prescription processing.
¾Encourage in-patients to
question
nurses about
medications that are unfamiliar or look or sound different
than expected.
¾Give verbal or telephone orders only when truly necessary
and never for chemotherapeutics. Include the drug's
intended purpose to ensure the clarity. Encourage staff to
read back all orders, spell the product name and state its
indication.
¾Affix "name alert" stickers to area where look or sound-alike
products are stored.
¾Store products with look or sound-alike names in different
locations in pharmacy, nursing units and other patient care
units (avoid alphabetical order).
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¾Consider the possibility of name confusion when adding a
new product to the formulary. Review information
previously published by safety agencies.
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Applicability
Suggested Actions
™Regulators (Health authorities and agencies)
¾Employ independent double checks in dispensing and
administrating process.
™Pharmaceutical companies
¾Encourage reporting of errors and potentially hazardous
condition with look and sound-alike product names.
™WHO: International Non-proprietary Names
(INN) Program
¾Change the appearance of look-alike product names on
computer screen, pharmacy and nursing unit shelf labels and
bins,
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 (hydrOXYzine and hydrALAzine) (DOPamine
™All settings where medications are ordered,
dispensed or administered (hospitals, clinics,
pharmacies …..)
and DOBUTamine).
™Patients, families and caregivers
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Safety Strategy in
Confused Drug Names
Potential
Problematic
Drug names
Cisplatin
and
Carboplatin
Ephedrine
and
Epinephrine
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Potential Errors
and Consequences
Specific Safety
Strategy
-Similarity in names leads to
confusion
-Doses for Carboplatin is
usually exceed the max dose
of Cisplatin
-Sever toxicity and death
may be associated with
accidental Cisplatin
overdoses.
-Mark the note of “Max Dose
Warning” for Cisplatin
-Do NOT store these two
drugs next each other
-Affix “Name Alert” stickers
in storage area
-Use both brand and generic
names and avoid
abbreviations
-NO verbal order
-The names of the two drugs
look very similar
-Both products may come in
a very similar packaging
-Do NOT store these two
drugs next each other
-Affix “Name Alert” stickers
in storage area
-Use the name Adrenaline
instead of Epinephrine
Opportunities for Patients
and Family Involvement
¾ Advise patients, families and caregivers regarding
potential problems related to LASA medications and how to
avoid them.
¾ Encourage them to learn the nonproprietary names as
key identifier of their medications.
¾ Instruct patients to alert their caregivers whenever a
medicine appears to vary in any way from what is usually
taken.
¾ Alert patients to the problem of LASA drug names when
obtaining medicines via the internet.
¾ Encourage patients to use their community pharmacies
as a source of information about LASA drugs.
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Potential Barriers
¾Continued production and marketing of LASA
drugs.
¾Costs related to the introduction of prescribing
technology applications.
¾Language barriers among multinational health
care professionals, especially when practicing in a
country where a different primary language is used.
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Safety Strategy in
Confused Drug Names
Potential
Problematic
Drug names
Potential Errors
and Consequences
Lamisil®
(Terbeniafen)
and
Lamictal®
(Lamotrigine)
-Epileptic patient who does
not receive Lamictal would be
inadequately treated and could
experience serious
consequences
-Conversely, patient
erroneously receives Lamictal
would be unnecessarily
subjected to a risk of potential
side effects
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Concor
(Bisoprolol)
and
Creon®
(Pancreatin)
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-Do NOT store these two
drugs next each other
-Affix “Name Alert” stickers
in storage area
-Use both brand and generic
names and avoid
abbreviations
-Mention the use and
purpose of medication in Rx
and drug labeling
-Encourage patients to learn
about their medications
Potential Barriers
Conclusion
¾LASA medication errors could lead to unwanted and
threatening consequences.
¾Systematic use of brand names instead of nonproprietary names.
¾Everyone in healthcare has a role in reducing LASA
medication errors.
¾Marketing pressure by pharmaceutical companies to
use brand names.
¾Pharmaceutical industry and regulatory authorities have
major roles to do in minimizing the possibility of LASA
medication errors.
¾Expanding industry use of brand recognition
packaging.
¾All settings where medications are ordered, dispensed or
administered should place a strategy to prevent LASA mixups.
¾Increase in development of multi-strength
combination products with common suffix descriptors.
¾Healthcare professionals, patients and their families and
caregivers have contributing roles in minimizing the drug
mix-up errors.
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- Similarity in brand names
leads to confusion
-Patient erroneously receiving
wrong drug would be
unnecessarily subjected to a
risk of potential side effects
and missing the right
treatment
Specific Safety
Strategy
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Questions or Comments
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THANKS
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