Look Alike & Sound Alike Drugs

To prevent medication errors involving drugs that may look alike or sound alike, consider the following practices:
Medication Ordering

Distinguishing Medications By:

Medication Administration/Storage:

Purchase DIFFERENT BRAND

Store in SEPARATE areas
DISTINGUISH names
TALL MAN lettering
Circle/highlight/underline differences

DOUBLE CHECK against order and MAR before

administration
HIGH ALERT meds require independent double
checks
Physical separation in storage (with warning on
shelf, different color bins)

POTENTIAL ERRORS & CONSEQUENCES

ERROR PREVENTION MEASURES

PRINT clearly
DO NOT ABBREVIATE drug name
Write both GENERIC and BRAND names
Write INDICATION for use

POTENTIALLY ERROR-PRONE
DRUG PAIRS /GROUPS OF DRUGS
Acetazolamide (Diamox)
Chlorothiazide (Diuril)
Amiloride (Midamor)
Amlodipine (Norvasc)
Amphotericin B (Fungizone)
Amphotericin B Liposomal (AmBisome,
Amphotec)
BuPROPion Sustained Release (Wellbutrin SR,
Zyban)
BuPROPion Extended Release (Wellbutrin XL)
BupreNORphine (Subutex)
BusPIRone (Buspar)
CARBOplatin (Paraplatin)
CISplatin (Platinol)

CarBAMazepine (Tegretol)
OXcarbazepine (Trileptal)

Similarity in generic and brand names may lead

to errors
Medications have the same indication
Similarity in generic names, dosage strengths,
and dosing may lead to errors
Medications have some overlapping indications
Confusion may occur between conventional and
liposomal formulations; products are NOT
INTERCHANGEABLE
Similarity in generic names may lead to errors
Both BuPROPions come in 150mg tablets but
can be dosed either twice daily (SR) or once
daily (XL).
These medications have different indications
Similarity in generic names may lead to errors
Doses appropriate for CARBOplatin usually
exceed the maximum safe dose of CISplatin

Similarity in generic and brand names may lead

to errors
Medications have some overlapping indications

(Rev Mar2015 Admin Policies 16.31 Appendix D, 16.30 Appendix A)

Physical separation in storage

Physical separation in storage

Liposomal formulation requires ID approval

Wellbutrin XL is on formulary, Wellbutrin SR is

non-formulary
Formulary status (bupreNORphine is nonformulary; bupreNORphine/naloxone is
formulary with restrictions)
Double check process with chemotherapy audit
tool for order review, compounding, and
administration
Tall Man lettering in pumps
Physical separation in storage

POTENTIALLY ERROR-PRONE
DRUG PAIRS /GROUPS OF DRUGS

POTENTIAL ERRORS & CONSEQUENCES

ERROR PREVENTION MEASURES

Carvedilol (Coreg)
Captopril (Capoten)
CHLORpromazine (Thorazine)
Prochlorperazine (Compazine)
ProMETHazine (Phenergan)
EScitalopram (Lexapro)
CITalopram (CELexa)
CloNIDine (Catapres)
CloZAPine (Clozaril, Fazaclo ODT)
ClonazePAM (KlonoPIN)
Divalproex (Depakote, Depakote Sprinkle)
Divalproex Extended Release (Depakote ER)
Valproic Acid/Sodium Valproate (Depakene)
DOPamine (Intropin)
DOBUTamine (Dobutrex)
DOCEtaxel (TaxoTERE)
PACLItaxel (TaxOL)

Medications have similar indications with similar

strengths which may lead to errors
Similar generic names may lead to errors
Medications have some overlapping indications

Physical separation in storage, with warning on shelf,

different color bins
Look-Alike alert decal on Omnicell lid
Encourage written orders with both generic and
brand names
Look-Alike alert decal on Omnicell lid

FluPHENazine (ProLIXIN)
FluPHENazine Decanoate (LONG acting ProLIXIN)
FluOXETine (ProZAC)
GlipiZIDE (Glucotrol)
GlyBURide (Micronase, Diabeta,Glynase)

Haloperidol Decanoate (LONG acting -- Haldol)

Haloperidol Lactate (SHORT acting -- Haldol)
Haemophilus B vaccine(Pedvax HIB, ActHIB,
Hiberix)
Hepatitis B vaccine (Recombivax HB, Engerix-B)

Similarity in generic names and indications may

lead to errors
Similarity in generic names may lead to errors
Medications have different indications
Confusion may occur between the regular release
and extended release formulations, which may
result in under/over-dosing
Similarity in names and strengths may lead to
errors
Similarity in generic and brand names may lead
to errors
Interchanging these two drugs may result in
serious dosing errors
Similarity in generic and brand names may lead
to errors
Medications have different indications
Similarity in names, strengths, and indications may
lead to errors
GlipiZIDE = shorter acting; max dose 40 mg/day
GlyBURide = longer acting; max dose 20 mg/day
Confusion may occur between the long acting and
immediate release injectable formulation which
may result in under/over-dosing
Similarities in names and reference to Haemophilus
B vaccine as HIB and Hepatitis B Vaccine as Hep
B may lead to errors

(Rev Mar2015 Admin Policies 16.31 Appendix D, 16.30 Appendix A)

Look-Alike alert decal on Omnicell lid

Preprinted order form for initial clozapine orders
Formulary status (Clonidine ODT is restricted)
Look-Alike alert decal on Omnicell lid
Pop-up in Siemens Rx system
Bar code verification in all MAK units
Physical separation in storage, with warning on shelf,
different colored bins
Double check process with chemotherapy audit
tool for order review, compounding, and
administration
Physical separation in storage, with warning on
shelf, different colored bins
Physical separation in storage, with warning on shelf,
different colored bins
Look-Alike alert decal on Omnicell lid

Look-Alike alert decal on Omnicell lid

Physical separation in storage, with warning on shelf,

different colored bins

POTENTIALLY ERROR-PRONE
DRUG PAIRS /GROUPS OF DRUGS

POTENTIAL ERRORS & CONSEQUENCES

Insulin Glargine (Lantus) long-acting basal

Insulin Lispro (HumaLOG) rapid-acting
Insulin Aspart (NovoLOG) rapid-acting
Insulin Regular (HumuLIN R, NovoLIN R)
Insulin 70/30 products (NovoLIN 70/30, NovoLOG
Mix 70/30)
Kadcyla (ado-trastuzumab emtansine)
Kyprolis (carfilzomib)

Similarity in names, strengths and concentration

ratios may lead to errors

LamiVUDine (Epivir)
LamoTRIgine (LaMICtal)
Terbinafine (LamISIL)

MetFORMIN (Glucophage)
MetroNIDAZOLE (Flagyl)
NiCARdipine (Cardene)
NiMODipine (Nymalize)
NIFEdipine (Procardia)
NORepinephrine (Levophed)
PHENYLephrine (Neosynephrine)
PredniSONE
PrednisoLONE
Rifampin (Rifadin)
Rifaximin (Xifaxin)
RisperiDONE (RisperDAL)
ROPINIRole (Requip)
SulfaSALAzine (Azulfidine, Sulfazine)
SulfaDIAzine

ERROR PREVENTION MEASURES

Similarity in brand names may lead to errors

Interchanging these two drugs may result in
serious dosing errors
Similarity in generic and brand names and
strengths may lead to errors
Consequences of errors may include StevensJohnson syndrome (lamotrigine)
Medications have different indications
Similarity in names and strengths may lead to
errors.
Medications have different indications
Similarity in generic names may lead to errors
Medications have some overlapping indications

Similar generic names and indications may lead to

errors
Similar generic names and indications may lead
to errors
Similarity in generic names may lead to errors
Medications have different indications
Similarity in generic and brand names may lead
to errors
Medications have different indications
Similarity in names may lead to errors
Medications have different indications

(Rev Mar2015 Admin Policies 16.31 Appendix D, 16.30 Appendix A)

Look-Alike alert decal on Omnicell lid

Formulary status (Insulin glargine and aspart are
restricted, insulin lispro is non-formulary)
On High Alert Medication List, requiring two
independent double checks

Double check process with chemotherapy audit

tool for order review, compounding, and
administration
Look-Alike alert decal on Omnicell lid

Look-Alike alert decal on Omnicell lid

Nicardipine is restricted to use by Anesthesia,

Neurology, and Neurosurgery
Physical separation in storage
Encourage written and verbal communication with
both generic and brand names
Physical separation in storage
Physical separation in storage
Physical separation in storage, with warning on shelf,
different colored bins
Encourage writing indications with medication
orders

POTENTIALLY ERROR-PRONE
DRUG PAIRS /GROUPS OF DRUGS
Tdap (Boostrix, Adacel)
DTaP (Infanrix)
Trastuzumab (Herceptin)
Ado-trastuzumab emtansine (Kadcyla)

(TopaMAX) Topiramate
(TopROL XL) Metoprolol Extended Release

TraZODone (Desyrel)
TraMADol (Ultram)
ValGANcyclovir (Valcyte)
ValACYclovir (Valtrex)
VinBLAStine (Velban)
VinCRIStine (Vincasar, Oncovin)
(ZyrTEC) Cetirizine
(ZypREXA) Olanzapine
Abbreviations for Extended Release
formulations of oral medications:
CD, DR, ER, SR, XL, XR, XT

POTENTIAL ERRORS & CONSEQUENCES

Similarity in names, strengths and concentration
ratios may lead to errors.
Tdap = adults; DTaP = children 6 weeks to <7 yr old
Similarity in generic names may lead to errors
Interchanging these two drugs may result in
serious dosing errors

Similarity in names may lead to errors.

Consequences of errors may include rapid
decrease in heart rate.
Medications have different indications
Similarity in generic names may lead to errors
Medications have different indications
Similarity in generic and brand names may lead
to errors
Medications have different indications
Similarity in names may lead to errors.
Similarity in brand names may lead to errors
Medications have different indications
Abbreviations do not all translate to
interchangeable dosing frequencies. Some
medications must be given once a day, others are
given twice a day.

(Rev Mar2015 Admin Policies 16.31 Appendix D, 16.30 Appendix A)

ERROR PREVENTION MEASURES

Product information posters showing which
one is for which age group

Double check process with chemotherapy audit

tool for order review, compounding, and
administration
Physical separation in storage
Look-Alike alert decal on Omnicell lid

Formulary status (tramadol is restricted)

Look-Alike alert decal on Omnicell lid
Physical separation in storage

Double check process with chemotherapy audit tool

for order review, compounding, and administration
Encourage use of generic names in written and
verbal communication
Need to double check dosing frequency whenever
the drug is ordered.