Adopt Strategies to Manage Look-Alike and/or Sound-Alike Medication Name Mix-Ups

ISMP has long advocated for increased awareness of look-alike and/or sound-alike medication name mix-ups and the implementation of safeguards to prevent them. To support this advocacy, ISMP maintains and periodically updates a comprehensive List of Confused Drug Names that have been reported to us and published in our newsletters, many of which are look-alike and/or sound-alike medication names. Referencing this list, along with your internal medication error data, you can identify and update a much more manageable list of error-prone medications with look-alike and/or sound-alike names that require safeguards in your organization. To assist with the prioritization and optimization of safeguards in your organization, we have compiled certain risk-reduction strategies previously published in this newsletter during the past 10 years. The risk-reduction strategies span all phases of the medication-use process as well as general categories such as medication storage and patient education.

Phases of the Medication-Use Process

Procurement

• When possible, avoid purchasing medications in which the manufacturer’s trademark symbol or corporate logo is larger than the name of the product because more attention will be drawn to the logo than the name of the product.

• Before new products are added to the formulary and/or inventory, use failure mode and effects analysis (FMEA) to ensure that all new medication product names are evaluated by practitioners who may use them. This process will help determine if the new products may be confused with another medication name.

• When new products (including products procured to manage drug shortages) are first received in the pharmacy, conduct an additional review to identify any unanticipated look-alike and/or sound-alike drug name concerns that may have been missed.

• Determine if the risk of a mix-up will be reduced if medications with look-alike names are purchased from different manufacturers. If so, purchase them from different manufacturers.

• When possible, purchase and stock different strengths/concentrations of drugs with potentially confusing, problematic drug names (e.g., morphine 2 mg/mL and HYDROmorphone 1 mg/mL).

Prescribing

• When prescribing (or communicating) medication orders, avoid drug name abbreviations (e.g., tPA, TXA), stemmed names (e.g., “statin”), or other shortened names (e.g., “nitro,” “pit”). Communicate the full generic name and/or the current brand name.

• Prescribe all medications electronically (rather than handwritten), or use preprinted order sets as much as possible if electronic prescribing is not available.

• If possible, display both the brand and generic name for medications with problematic look-alike names in the medication description field, on product selection menus, and for search choices to aid in recognition of the medication (e.g., lamoTRIgine [LAMICTAL] and levETIRAcetam [KEPPRA], see #21 in the ISMP Guidelines for Safe Electronic Communication of Medication Information).  

• Prebuild order sets with the drug’s indication to guide the prescriber’s selection among problematic look-alike and/or sound-alike medication names (e.g., hydrOXYzine for pruritus, hydrALAZINE for hypertension). Displaying the medication’s indication on order screens helps practitioners avoid confusion between problematic medications with look-alike and/or sound-alike names, as most are used to treat different conditions.

• To reduce errors with sound-alike medication names, limit verbal or telephone orders to emergencies, or when the prescriber is physically unable to electronically enter or write orders.

  • Never allow verbal or telephone orders for chemotherapy (except to hold or discontinue therapy).

  • When verbal or telephone orders must be provided, require the receiving practitioner to directly enter the complete medication order into the patient’s electronic health record and to read back the order to the prescriber, spelling the medication name. Use a phonetic alphabet (e.g., “T” as in “Tango,” “C” as in “Charlie”) when reading back the spelled drug name.

  • Ask the prescriber for the medication’s indication if it has not been provided. Transcribe the indication directly in the medication order.

Dispensing

• When verifying a medication order, ensure that the prescribed medication, dose, dosage form, route of administration, and indication for use make sense in the context of the patient’s condition. If the drug’s indication is not clearly stated within the order, and the patient’s condition or diagnosis does not support the drug’s intended use, clarify the medication with the prescriber. For example, if an order for clonazePAM 0.5 mg twice daily is misheard as cloBAZam, and the indication is communicated for the treatment of anxiety, not to control seizures, both the dose and the indication would offer clues that perhaps the prescribed medication is actually clonazePAM, not cloBAZam. Do not make assumptions or guess when verifying an order; instead, seek clarification.

• When preparing to dispense and deliver a medication, one or more pharmacy staff should read the container label when selecting it, confirm the product before providing it to someone else to check, and again when delivering it to a patient care unit. Never rely solely on a partially turned label or color of the label, cap, auxiliary warning, or company graphics to properly identify a product.

• Employ barcode scanning technology when stocking medications in the pharmacy inventory, dispensing medications, refilling automated dispensing cabinets (ADCs) or robotic dispensing machines, and prior to compounding sterile products, including medications or solutions used in automated compounding devices and intravenous (IV) workflow management systems.

Administration

• For problematic look-alike and/or sound-alike drug names, include the generic name, current brand name, and indication on medication administration records (MARs).

• Before administration, verify that the medication’s indication, dose, dosage form, and route of administration align with the patient’s condition or diagnosis.

• Review the medication’s purpose with the patient or caregiver before administration. For example, if you are a nurse administering medications, ask, “Do you have any questions before I give your child’s antiseizure medication, tiaGABine?” This could help a parent identify an error if their child takes tiZANidine to manage spasticity (from a neurological disorder) at home.

• Similar to dispensing, before administering a medication, read the container and/or pharmacy label when obtaining it from unit stock, a patient-specific bin or drawer, or an ADC; before scanning and providing it to the patient; and when discarding the container. Never rely solely on a partially turned label or color of the label, cap, auxiliary warning, or company graphics to properly identify a product.

• Employ bedside barcode scanning technology consistently prior to medication administration. If a medication barcode does not scan, a clear process to quickly report and resolve the issue is necessary instead of bypassing the scanning process. In a rare occurrence in which a barcode does not scan, bypassing the scanning process is only appropriate after confirming the correct medication, often by requiring an independent double check with a second practitioner.

General Categories

Storage

• Store medications with problematic, error-prone, look-alike and/or sound-alike names in separate physical locations away from each other.

  • In the pharmacy, if automated storage technologies (e.g., carousels) are not used, inform staff about changes in the location of a problematic product through signage or shelf talkers.

  • In patient care units, avoid open matrix ADC drawer configurations for stocking medications with look-alike names (or packaging), and instead use locked-lidded pockets or separate bins, cubies, drawers, or ADC cabinets to segregate storage.

  • In anesthesia carts and trays, strive to organize all vials in a label-up instead of cap-up position, and avoid close proximity of medications with look-alike and/or sound-alike medication names (or look-alike packaging and labeling, particularly cap colors). (Vendors need to design drawers to accommodate this type of storage.)  

• Change the appearance of look-alike medication names displayed on shelves and bins by presenting the names using tall man letters (see the section on nomenclature), bold font, different colored font, and/or highlighting or circling critical differentiating information. Reserve auxiliary warning labels on medication containers and storage bins for the most problematic look-alike products.

Nomenclature

• For problematic look-alike medication names, use tall man lettering on electronic prescribing drug selection screens, order sets, ADC screens, smart infusion pump screens, MARs, and any other drug communication tool, to draw attention to the key differences in similar drug names.

  • To standardize the letters presented in uppercase and bold font, follow the recommendations on the US Food and Drug Administration (FDA) and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters.

• If mnemonics or short names are permitted to search for products or populate fields without entering the full drug name, require practitioners to enter at least 5 letters during a drug name search to reduce the number of medications, including those with look-alike and/or sound-alike names, that appear together on a screen (see #19 in the ISMP Guidelines for Safe Electronic Communication of Medication Information).    

Staff Education

• During orientation and annually, educate practitioners about the risks of confusing problematic, error-prone, look-alike and/or sound-alike medication names and abbreviations; where in the medication-use process these risks might be encountered; how to access the organizational list of problematic look-alike and/or sound-alike medication names; and the required risk-reduction strategies to implement.

  • Draw special attention to specific medications with look-alike or sound-alike names that can cause harm if confused, and promote knowledge of and compliance with medication-specific risk-reduction strategies.

  • Stress the importance of barcode scanning as a tool that is more effective in consistently identifying correct medications than other manual processes.

  • Provide education about the purpose of tall man lettering, as this safeguard is more successful for those who are aware of its purpose.

  • Provide education about the differences between lipid-based and conventional products with look-alike generic names (e.g., DOXIL [DOXOrubicin liposomal] and ADRIAMYCIN [DOXOrubicin conventional]) and the steps that should be taken to reduce confusion between these products.

  • Encourage reporting of errors and hazards with look-alike and/or sound-alike medication names, and use the information to enhance error-reduction strategies.

  • Share external literature, ISMP Action Agendas, and internal error reports involving similar medication names and the actions the organization is taking to avoid mix-ups. Share good catches of errors prevented due to barcode scanning.

Patient Education

• Educate patients taking a medication with a problematic look-alike and/or sound-alike name about the risk of mix-ups and how to avoid them. If the patient is educated about common errors, they might detect a dispensing error by reading the label when picking up their medication.

• Encourage patients to question medications that look different than expected, and to persist until satisfactory resolution of their concern. This line of questioning might detect an error with a look-alike and/or sound-alike medication.

• Require mandatory patient education in outpatient settings before dispensing a medication with a known, problematic look-alike and/or sound-alike name. When possible, open the prescription bottle with the patient to visually confirm the expected medication.

Metrics

• Establish process and outcome measures and collect data periodically to assess the effectiveness of safeguards intended to reduce errors and patient harm associated with medication names that look and/or sound alike. For example: 

  • Track and investigate errors in dispensing and evaluate if look-alike and/or sound-alike drug names played a role

  • Monitor and observe barcode scanning compliance in the pharmacy, during ADC transactions, and prior to medication administration

• Identify and act on issues uncovered during the analysis of process and outcome measures associated with medications that have look-alike and/or sound-alike names. Rather than assuming that more education is needed, take steps to understand the system causes of low compliance or mix-ups. For example, if data shows low compliance with barcode scanning of saline lock flushes prior to administration, ask: Is this a new manufacturer and the barcode has not yet been added to the system? Is there an issue with how the label or barcode is placed on the syringe? Is there a problem with the barcode scanner’s ability to scan the barcode?

• Provide feedback to staff about data being monitored, analysis of that data, performance improvement initiatives in response to the data, and planned actions.

^{Suggested citation:}

^{Institute for Safe Medication Practices (ISMP). Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. ISMP Medication Safety Alert! Acute Care. 2022;27(11):1-4.}