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Improve Core Processes for Dispensing Medications:
Separate Drugs that Look or Sound Alike

Pharmaceutical companies sometimes choose drug names that are spelled or pronounced like other names on the market. Unfortunately, similarly named medications can have very different therapeutic uses. Patients have received incorrect medications due to name confusion, sometimes suffering serious adverse drug events. The same problem occurs with different medications that are packaged in similar ways. Some medications come in multiple strengths from the same manufacturer with exactly the same packaging, with only a small note on the label about the differences in strength. Separating medications so look-alikes and sound-alikes are not near each other helps reduce the chances that they will be mixed up.


Tips
  • Minimize the availability of multiple drug strengths.
  • Label medications with both generic and trade names to make them easier to distinguish.
  • Store rarely used look-alike or sound-alike medications in the pharmacy, not on patient care units.
  • Use additional warning labels to alert staff of look-alike or sound-alike drugs, especially those with serious side effects.
  • Educate patients about look-alikes and sound-alikes so that after discharge they can watch for errors at outpatient and retail pharmacies.
  • Be sure your computerized order entry system alerts users to possible confusion of look-alike or sound-alike drugs, especially when they can be looked up by name.