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Hospital Name
Look-A-Like ∕ Sound-A-Like Drugs
|
Potential Problematic Drug Names |
Writing Practices |
Specific Safety Strategies |
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Cisplatin / Carboplatin |
CISPLATIN (print in all CAPS) CARBOPLATIN (print in all CAPS) |
Maximum dose warnings listed in HBOC. Agents stored separately on shelf. Use generic names when prescribing, not chemical names. Pharmacists obtain roadmaps for patients receiving chemotherapy. Verbal orders are never acceptable for chemotherapy. |
|
Insulin Products |
Novolin NPH or Novolin R or Novolin 70/30 Novolog or Novolog 70/30 (print in all CAPS) |
Limit the variety of insulin products stored in patient care areas (Emergency Room / OR). Remove patient specific insulin vials from stock upon discharge. |
|
Lipid Based Amphotericin B |
Ambisome (Brand Name ) Amphotericin B (conventional name) |
Staff aware of differences between conventional and lipid-based formulations. Dosing ranges listed in HBOC for dosing checks. Use brand names for ordering lipid-based amphotericin products. Stored in pharmacy only. Lipid-based amphotericin limited to one specific brand (Ambisome). |
|
Vinblastine / Vincristine |
VINBLASTINE (print in all CAPS) VINCRISTINE (print in all CAPS) |
Maximum dose warnings in HBOC to alert staff. Agents stored separately in refrigerator. Pharmacists obtain roadmaps for patients receiving chemotherapy. |
|
Hydromorphone / Morphine |
Dilaudid (Brand Name) Morphine |
Hydromorphone is only stored in the pharmacy pyxis. Hydromorphone is stored separately from morphine. Ensure that health care providers are aware that these two products are not interchangeable. |
|
Doxorubicin / Daunorubicin |
DOXORUBICIN (print in all CAPS) DAUNORUBICIN (print in all CAPS) |
Maximum dose warnings listed in HBOC. Agents stored separately on shelf. Pharmacists obtain roadmaps for patients receiving chemotherapy. Verbal orders are never acceptable for chemotherapy. |
|
Morphine Liquid |
Morphine Liquid 20 mg / ml Morphine Liquid 2 mg / ml (list concentration) |
Do not store these agents near one another if both products are available (e.g., pharmacy, pyxis units). |
|
Zyrtec / Zantac |
Cetirizine (Generic Only) Zantac or Ranitidine |
Flagged in the Verbal Order Policy. (see general recommendations) |
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Clonidine / Clonazepam |
Catapres (Clonidine) Klonopin (Clonazepam) (print trade & generic name) |
Flagged in the Verbal Order Policy. (see general recommendations) |
|
Diflucan / Diprivan |
Diflucan or Fluconazole Propofol (Generic Only) |
Flagged in the Verbal Order Policy. (see general recommendations) |
General Recommendations for Preventing Drug Name Mix-ups
· Maintain awareness of look-alike and sound-alike drug names as published by various safety agencies
· Clearly specify the dosage form, drug strength, and complete directions on prescriptions. These variables may help staff differentiate products.
· With name pairs known to be problematic, reduce the potential for confusion by writing prescriptions using both the brand and generic name.
· Include the purpose of medication on prescriptions. In most cases drugs that sound or look similar are used for different purposes.
· Alert patients to the potential for mix-ups, especially with known problematic drug names. Advise ambulatory care patients to insist on pharmacy counseling when picking up prescriptions, and to verify that the medication and directions match what the prescriber had told them.
· Encourage inpatients to question nurses about medications that are unfamiliar or look or sound different than expected.
·
Give verbal or telephone orders only when
truly necessary, and never for chemotherapeutics. Include the
drug’s intended purpose to ensure clarity. Encourage staff to read
back all orders, spell the product name, and state its indication.