Look-alike drugs

Lake, C.R., Quirk, R.S. CNS stimulants and the look-alike drugs. Psychiatr. Clin. North Am. 7 689, 1984. 

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. 

S. Avoid look-alike drugs. They have nothing to recommend them. 

Look-alike drugs Tablets and capsules made to resemble pharmaceutical stimulants and depTessants. such as amphetamines and Quaalude sold on the black market or in head shops. 

Look-alike drugs, 49-50, 72 Lorazepam (Ativan), 74 Love drugs, 108, zro LSD [lysergic acid diethylamide). 6, 16, 33, 101, ro6, 162 discussed, 9 5-97 first-person comments on, 208,... 

Synonyms Street speed Look alike drugs White crosses Pink hearts Black beauties 357s ... 

Ephedra was also sold in combination with many other herbs in obscure combinations. Labels frequently listed 10 or 15 different herbs, but, analysis usually disclosed only the ephedra alkaloids and caffeine as present in sufficient quantities to be physiologically active. After several well-publicized accidental deaths, products clearly intended for abuse, such as herbal ecstasy, and other look-alike drugs (products usually containing ephedrine or phenylpropanolamine designed to look like illicit methamphetamine, but in concentrations higher than recommended by industry or the FDA) were withdrawn from the market. Labels on these products were frequently misleading. For example, one might suppose that a product called Ephedrine 60 contained 60 mg of ephedrine when, in fact, the actual ephedrine content was 25 mg. 

Garriott JC, Simmons LM, et al. Five cases of fatal overdose from caffeine-containing "look-alike" drugs. J Analyt Toxicol 1985 9 141-3. 

To prevent sound-alike and look-alike errors, physicians must be encouraged to include complete directions, strengths, route of administration, and indication (purpose) for use. All these elements can serve as identifiers. It cannot be stressed enough that even if such information is lacking on orders, by knowing a drug s purpose, as well as the patient s problems, skilled... 

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. 

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

Another drawback of look-alikes is their cost they are a very expensive way to buy the drugs they provide. 

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. 

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. 

Remove high risk medications, such as concentrated electrolyte solutions, from patient care areas Label high risk drugs clearly to indicate their danger Remove or clearly differentiate look alike or sound alike drugs... 

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. 

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