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News Release

Updated ISMP List of Often Confused Drug Names Now Available

More than 80 Pairs Added to Make Resource the Most Comprehensive

The Institute for Safe Medication Practices (ISMP) has revised its list of drug names that are often confused, including look-alike and sound-alike name pairs. More than 80 name pairs have been added since the last version. The refreshed list now incorporates the drug names that use U.S. Food and Drug Administration (FDA)-approved and ISMP-recommended tall man (mixed-case) letters.

“To update the list, we drew from what has been published in ISMP’s medication safety newsletters, following our analysis of the reports submitted to ISMP, as well as the current FDA list,” says Michael J. Gaunt, PharmD, senior manager, error reporting programs for ISMP. “Our goal was to give healthcare practitioners all the information that they need in one reference.”

ISMP hopes that healthcare organizations will use the current list to determine which medications require special safeguards to reduce the risk of errors. Strategies for risk reduction could include:

  • Using both brand and generic names on prescriptions and labels

  • Including the purpose of the medication on prescriptions

  • Configuring computer systems to require a minimum of the first five letters of a drug name during product searches to limit similar names from appearing together on the same screen

  • Changing the appearance of look-alike product names to draw attention to their differences

For a copy of the up-to-date ISMP List of Confused Drug Names, click here.


Renee Brehio, Medication Safety Analyst and Editor,

About the Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 30 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work.


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