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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.