Look-alike drug names

The first step is to reduce label clutter. Only essential information, such as the brand and generic names, strength or concentration, and warnings, should appear prominently on the front label. Numerous deaths have been prevented through the addition of a warning to concentrated vials of injectable potassium chloride, for example. Another step includes the use of typeface to enhance distinctive portions of look-alike drug names on look-alike packaging. 

JCAHO Sentinel Event Alert No. 19 Look-alike, sound-alike drug names. May 2001. Available at www.jcaho.org, accessed August 5, 2002. 

Healthcare professionals can either complete a report form or contact the ISMP—Spain directly by e-mail, fax, or telephone to report medication errors with complete confidentiality. The types of medication errors submitted include confusion over look-alike or sound-alike drug names, ambiguity or similarity in packaging or labeling. 

Medication errors involving look-alike/sound-alike drug names can cause serious patient harm. For instance, a number of errors have been reported and published on the confusion between Lamisil and Lamictal . Reading these two names quickly, one can easily see how they could be confused, but re-design of the labels to highlight the differences rather than the similarities makes them markedly distinct (Figure 12.1). 

Use tail-man lettering to distinguish look-alike/sound-alike drug names on manufacturer s bulk bottle labelling, prescription labels, medication administration records and in hospital and community pharmacy computer systems. 

Packaging Standards. While there is no evidence that trademark colors and logos on boxes pose a problem, the use of color on bottle tops and labels creates many difficulties. There are dozens of drugs whose names are quite different but whose packages look alike. This creates the potential for error when people see what they expect to see on the label. 

Lambert BL, Lin SJ, Chang KY, Gandhi SK. Similarity as a risk factor in drug-name confusion errors The look-alike (orthographic) and sound-alike (phonetic) model. Med Care 1999 37 1214-25. 

Look- and sound-alike medications Do not store problem medications alphabetically by name Place the purpose of the medication on the prescription Establish a safe policy and practice for verbal orders Use both the generic and brand name of the drug Provide patients with written information about their medications 21... 

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