Download Sound-Alike/Look-Alike Drugs for Hospital

UP Health System – Marquette
Pharmacy and Therapeutics Committee
Medication Guideline
Sound-Alike/Look-Alike Drugs for Hospital
Potential Problematic
Drug Names
Drugs as They Would Appear on
MAR
Potential Errors and Consequences
Safety Strategies
1.
Cisplatin and
Carboplatin
Platinol (CISplatin)
Paraplatin (CARBOplatin)
Doses appropriate for carboplatin
usually exceed the maximum safe
dose of cisplatin. Severe toxicity and
death has been associated with
accidental cisplatin overdoses.
Store separately
Dose limits in Paragon
TALLman letters: CISplatin,
CARBOplatin
2.
Fentanyl and Sufentanil
Sublimaze (FENTanyl)
Sufenta (SUfentanil)
The products are not
interchangeable. Confusion has
resulted in episodes of respiratory
arrest due to potency differences
between these drugs.
No floor stock, only in OR
Store separately
3.
Insulin products
LANtus (Insulin Glargine)
Novolog and Novolin
Novolin 70/30 and
Novolog Mix 70/30
HUMAlog
Similar names, strengths and
concentration ratios of some
products (e.g., 70/30) have
contributed to medication errors.
Floor stock – regular - Humulin R
Doublecheck by nursing
TALLman letters
NOVOlin (Human Insulin Products)
NOVOlog (Human Insulin Aspart)
Novolin 70/30 (70% Isophane
Insulin [Nph] And 30% Insulin
Injection [Regular])
Novolog Mix 70/30 (70% Insulin
Aspart Protamine Suspension And
30% Insulin Aspart)
4.
Lipid-based
amphotericin products
vs. conventional forms
of amphotericin
Abelcet (AMPHotericin B Lipid
Complex)
Amphocin, Fungizone Intravenous
(AMPHotericin B Desoxycholate)
Confusion may occur between the
liposomal and the conventional
formulations because of name
similarity. The products are not
interchangeable.
On restricted formulary
Only 1 lipid based available
Only 1 conventional available
Store separately
No floor stock
Paragon prints the brand name
5.
Taxol and Taxotere
TAXol (Paclitaxel)
TAXOtere (Docetaxel)
Confusion can result in serious
adverse outcomes since they have
different dosing recommendations
and use in various types of cancer.
Dose limits in Paragon
Store separately
TALLman letters
6.
Vinblastine and
Vincristine and
Vinorelbine
Velban (VINblasTINE)
Oncovin (VINcrisTINE)
Navelbine (Vinorelbine)
Fatal errors have occurred, often due
to name similarity, when patients
were erroneously given Vincristine
intravenously, but at the higher
Vinblastine dose.
Dose limits in Paragon
Store separately
Pharmacist to pharmacist
doublecheck only
TALLman letters
7.
Celebrex and Celexa and
Cerebyx
CELEbrex (Celecosib)
CELExa (Citalopram Hydrobromide)
CEREbyx (Fosphenytoin)
Patients affected by a mix-up
between these three drugs may
experience a decline in mental
status, lack of pain or seizure control,
or other serious adverse events.
TALLman letters
Store separately
Document created: 01/01.
Revised: 06/16.
Cross Reference: Safe Medication Practices (#100-170)
UP Health System - Marquette
A Duke Lifepoint Hospital
Marquette, MI 49855
This is a confidential professional/peer review and quality assessment document of Marquette General Health System of Marquette, MI. It is
protected from disclosure pursuant to the provisions of MCL 333.20175, MCL 333.21513, MCL 21515, MCL 331.531, MCL 331.533, MCL
330.1143a, and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited.
UP Health System – Marquette
Pharmacy and Therapeutics Committee
Medication Guideline
Potential Problematic
Drug Names
8.
Diflucan – Diprivan
Drugs as They Would Appear on
MAR
DIFLucan (Fluconazole)
DIPrivan (Propofol)
DIPrivan (only when ordered as
‘dispense as written’
Potential Errors and Consequences
Safety Strategies
Name similarity has the potential for
mix-ups of two agents with totally
different indications. Under
treatment of an infection or over
sedation.
TALLman letters
Store separately
9.
Primacor – Primaxin
PRImacor (Milflnone Lactate)
PRImaxin (Imipenem & Cilastatin
Sodium)
Name similarity has the potential for
mix-ups of two agents with totally
different indications. Under
treatment of an infection or
cardiovascular complications.
TALLman letters
Store separately
10.
Zantac – Xanax
ZANtac (Ranitidine Hydrochloride)
XANax (Alprazolam)
Name similarity has the potential for
mix-ups of two agents with totally
different indications.
TALLman letters
Store separately
11.
Oxycontin
Roxicodone
MSIR
Accidental selection of the wrong
concentration and
prescribing/labeling the product
contributes to errors.
12.
Methadone
Methylphenidate
OXYcontin (Oxycodone
Hydrochloride)
ROXIcodone (Oxycodone
Hydrochloride)
MSIR (Morphine Sulfate)
Dolophine (METHadone
Hydrochloride)
Ritalin (METHylphenidate
Hydrochloride)
Stickers on bottom of blue
narcotic boxes will include
TALLman letters.
Separate drugs in the unit narcotic
cabinet
TALLman letters
Separate drugs in the drug
narcotic cabinet.
Additional Safety Measures:
Similar names and some similar
strengths have contributed to
medication errors. This may
represent significant overdose,
leading to serious adverse events.
Limit verbal orders
Stickers – narc boxes
Awareness of issues for formulary review
Brand/generic names on MAR
Dose limits
Document created: 01/01.
Revised: 06/16.
Cross Reference: Safe Medication Practices (#100-170)
UP Health System - Marquette
A Duke Lifepoint Hospital
Marquette, MI 49855
This is a confidential professional/peer review and quality assessment document of Marquette General Health System of Marquette, MI. It is
protected from disclosure pursuant to the provisions of MCL 333.20175, MCL 333.21513, MCL 21515, MCL 331.531, MCL 331.533, MCL
330.1143a, and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited.
UP Health System – Marquette
Pharmacy and Therapeutics Committee
Medication Guideline
Sound-Alike/Look-Alike Drugs for Ambulatory Care and Home Health
Potential Problematic
Drug Names
Brand Name(s) (UPPERCASE)
and Generic (lowercase)
1.
Celebrex and Celexa
and Cerebyx
CELEBREX (celecoxib)
CELEXA (citalopram
hydrobromide)
CEREBYX (fosphenytoin)
2.
Clonidine and Klonopin
CATAPRES (clonidine)
KLONOPIN (clonazepam)
3.
Insulin products
HUMULIN (human insulin
products)
HUMALOG (insulin lispro)
Humalog and Humulin
Novolog and Novolin
Humulin and Novolin
Humalog and Novolog
Novolin 70/30 and
Novolog Mix 70/30
NOVOLIN (human insulin
products)
NOVOLOG (human insulin aspart)
Potential Errors and Consequences
Patients affected by a mix-up between
these three drugs may experience a
decline in mental status, lack of pain or
seizure control, or other serious adverse
events.
The generic name for clonidine can easily
be confused as the trade or generic
name of clonazepam.
Similar names, strengths and
concentration ratios of some products
(e.g., 70/30) have contributed to
medication errors. Mix-ups have also
occurred between the 100 unit/mL and
500 units/mL insulin concentrations.
NOVOLIN 70/30 (70% isophane
insulin [NPH] and 30% insulin
injection [regular])
NOVOLOG MIX 70/30 (70% insulin
aspart protamine suspension and
30% insulin aspart)
4.
5.
Lorazepam and
Alprazolam
Xanax and Zantac
Metformin and
Metronidazole
ATIVAN (lorazepam)
XANAX (alprazolam)
ZANTAC (ranitidine hydrochloride)
ZYRTEC (cetirizine hydrochloride)
GLUCOPHAGE (metformin)
FLAGYL (metronidazole)
6.
Oxycontin
Roxicodone
MSIR
OXYCONTIN (oxycodone
hydrochloride)
ROXICODONE (oxycodone
hydrochloride)
MSIR (morphine sulfate)
7.
Prilosec and Prozac
PRILOSEC (omeprazole)
PROZAC (fluoxetine
hydrochloride)
Document created: 01/01.
Revised: 06/16.
Cross Reference: Safe Medication Practices (#100-170)
Name similarity has the potential for mixups of these agents with totally different
indications and potencies. A mix-up,
especially in the elderly, would likely
cause excessive sedation and increase
fall risk.
Potentially serious mix-ups between
metronidazole and metformin have been
linked to look-alike packaging (both bulk
bottles and unit-dose packages).
Metformin is contraindicated in certain
clinical situations where use might
contribute to lactic acidosis.
Administration of intravenous iodinated
contrast media during radiological
procedures has been associated with
acute renal dysfunction.
Accidental selection of the wrong
concentration and prescribing/labeling
the product contributes to errors.
Suggested Safety Strategies
Maintain awareness of lookalike and sound-alike drug
names as published by various
safety agencies.
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 patients to
insist on pharmacy counseling
when picking up prescriptions,
and to verify that the
medication and directions
match what the prescriber has
told them.
Encourage patients to question
nurses about medications that
are unfamiliar or look or sound
different than expected.
Store products with look or
sound-alike names in different
locations, including in patient
homes.
Ask patient to verify the correct
medication by asking them the
purpose of the medication.
Name similarity has resulted in frequent
mix-ups.
Double check
Separate storage
UP Health System - Marquette
A Duke Lifepoint Hospital
Marquette, MI 49855
This is a confidential professional/peer review and quality assessment document of Marquette General Health System of Marquette, MI. It is
protected from disclosure pursuant to the provisions of MCL 333.20175, MCL 333.21513, MCL 21515, MCL 331.531, MCL 331.533, MCL
330.1143a, and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited.
UP Health System – Marquette
Pharmacy and Therapeutics Committee
Medication Guideline
Potential Problematic
Drug Names
8.
9.
10.
11.
Topamax and Toprol XL
Zyprexa and Zyrtec
Cisplatin and
Carboplatin
Taxol and Taxotere
Brand Name(s) (UPPERCASE)
and Generic (lowercase)
TOPAMAX (topiramate)
TOPROL-XL (metoprolol)
ZYPREXA (olanzapine)
ZYRTEC (cetirizine)
PLATINOL (cisplatin)
PARAPLATIN (carboplatin)
TAXOL (paclitaxel)
TAXOTERE (docetaxel)
12.
Vinblastine and
Vincristine and
Vinorelbine
VELBAN (vinblastine)
ONCOVIN (vincristine)
NAVELBINE (vinorelbine)
13.
Methadone
Methylphenidate
14.
Asacol and Oscal
DOLOPHINE (methadone
hydrochloride)
RITALIN (methylphenidate
hydrochloride)
ASACOL (mesalamine)
OSCAL (calcium carbonate)
Document created: 01/01.
Revised: 06/16.
Cross Reference: Safe Medication Practices (#100-170)
Potential Errors and Consequences
Error is likely attributable to the
similarity in names with the “X” in XL of
the beta-blocker, Toprol XL, looking like
the ending of Topamax, an
anticonvulsant. In addition, available
dosage strengths (25, 50, 100, 200) are
identical, adding to likelihood of mix-up.
Imprint on the Topamax tablet is “TOP”
on one side and 25 mg strength has “25”
on the other, risking confusion with
Toprol XL 25 mg.
Patients needing Topamax may develop
seizures and/or have adverse effects
with Toprol XL. Patients needing a betablocker may have worsened disease
symptoms without treatment.
Name similarity has resulted in frequent
mix-ups between Zyrtec, an
antihistamine, and Zyprexa, an
antipsychotic. Patients who receive
Zyprexa in error have reported dizziness,
sometimes leading to a related injury
from a fall. Patients on Zyprexa for a
mental illness have relapsed when given
Zyrtec in error.
Doses appropriate for carboplatin usually
exceed the maximum safe dose of
cisplatin. Severe toxicity and death has
been associated with accidental cisplatin
overdoses.
Confusion can result in serious adverse
outcomes since they have different
dosing recommendations and use in
various types of cancer.
Fatal errors have occurred, often due to
name similarity, when patients were
erroneously given Vincristine
intravenously, but at the higher
Vinblastine dose.
Similar names and some similar strengths
have contributed to medication errors.
This may represent significant overdose,
leading to serious adverse events.
Name similarity has resulted in mix-up
between two agents with different
indications. May result in under
treatment of ulcerative colitis or
hypocalcemia or result in adverse effects
of unintended agent.
Suggested Safety Strategies
Maintain awareness of lookalike and sound-alike drug
names as published by various
safety agencies.
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 patients to
insist on pharmacy counseling
when picking up prescriptions,
and to verify that the
medication and directions
match what the prescriber has
told them.
Encourage patients to question
nurses about medications that
are unfamiliar or look or sound
different than expected.
Store products with look or
sound-alike names in different
locations, including in patient
homes.
Ask patient to verify the correct
medication by asking them the
purpose of the medication.
UP Health System - Marquette
A Duke Lifepoint Hospital
Marquette, MI 49855
This is a confidential professional/peer review and quality assessment document of Marquette General Health System of Marquette, MI. It is
protected from disclosure pursuant to the provisions of MCL 333.20175, MCL 333.21513, MCL 21515, MCL 331.531, MCL 331.533, MCL
330.1143a, and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited.
UP Health System – Marquette
Pharmacy and Therapeutics Committee
Medication Guideline
Potential Problematic
Drug Names
Brand Name(s) (UPPERCASE)
and Generic (lowercase)
15.
Diabeta and Zebeta
DIABETA (glyburide)
ZEBETA (bisoprolol fumarate)
16.
Plavix and Paxil
PLAVIX (clopidogrel bisulfate)
PAXIL (paroxetine hydrochloride)
17.
DTaP and Tdap
Pediatric formulation of
diphtheria toxoid, tetanux toxoid,
and acellular pertussis antigens:
DTAP (DAPTACEL, INFANRIX,
TRIPEDIA)
Potential Errors and Consequences
Name similarity has resulted in mix-up
between two agents with different
indications. May result in under
treatment of hyperglycemia or
hypertension result in adverse effects of
unintended agent.
Name similarity has resulted in mix-up
between two agents with different
indications. May result in under
treatment of stroke prevention or
depression or result in adverse effects of
unintended agent.
Name similarity has resulted in frequent
mix-ups.
Double check
Separate storage
Suggested Safety Strategies
Check for age appropriateness.
Adult formulation of diphtheria
toxoid, tetanux toxoid, and
acellular pertussis antigens: TDAP
(ADACEL, BOOSTRIX)
Document created: 01/01.
Revised: 06/16.
Cross Reference: Safe Medication Practices (#100-170)
UP Health System - Marquette
A Duke Lifepoint Hospital
Marquette, MI 49855
This is a confidential professional/peer review and quality assessment document of Marquette General Health System of Marquette, MI. It is
protected from disclosure pursuant to the provisions of MCL 333.20175, MCL 333.21513, MCL 21515, MCL 331.531, MCL 331.533, MCL
330.1143a, and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited.