SFGH Pharmacy Policies Rainbow Chart



Look Alike & Sound Alike Drugs

To prevent medication errors involving drugs that may look alike or sound alike, consider the following practices:

|Medication Ordering |Distinguishing Medications By: |Medication Administration/Storage: |

|PRINT clearly |Purchase DIFFERENT BRAND |DOUBLE CHECK against order and MAR before administration |

|DO NOT ABBREVIATE drug name |Store in SEPARATE areas |HIGH ALERT meds require independent double checks |

|Write both GENERIC and BRAND names |DISTINGUISH names |Physical separation in storage (with warning on shelf, different color |

|Write INDICATION for use |TALL MAN lettering |bins) |

| |Circle/highlight/underline differences | |

|Potentially Error-Prone |Potential Errors & Consequences |Error Prevention Measures |

|Drug Pairs /Groups of Drugs | | |

|Acetazolamide (DiaMOX®) |Similarity in generic and brand names may lead to errors |Physical separation in storage |

|Chlorothiazide (DiuRIL®) |Medications have the same indication | |

|AmiloRIDE (Midamor®) |Similarity in generic names, dosage strengths, and dosing may lead to |Physical separation in storage |

|AmlodiPINE (Norvasc®) |errors | |

| |Medications have some overlapping indications | |

|Amphotericin B (Fungizone®) |Confusion may occur between conventional and liposomal formulations; |Liposomal formulation requires ID approval |

|Amphotericin B – Liposomal (AmBisome®, Amphotec®) |products are NOT INTERCHANGEABLE | |

|BuPROPion Sustained Release (Wellbutrin SR®, Zyban®) |Similarity in generic names may lead to errors |Wellbutrin XL is on formulary, Wellbutrin SR is non-formulary |

|BuPROPion Extended Release (Wellbutrin XL®) |Both BuPROPions come in 150mg tablets but can be dosed either twice |Formulary status (bupreNORphine is non-formulary; bupreNORphine/naloxone |

|BupreNORphine (Subutex®) |daily (SR) or once daily (XL). |is formulary with restrictions) |

|BusPIRone (Buspar®) |These medications have different indications | |

|CARBOplatin (Paraplatin®) |Similarity in generic names may lead to errors |Double check process with chemotherapy audit tool for order review, |

|CISplatin (Platinol®) |Doses appropriate for CARBOplatin usually exceed the maximum safe dose |compounding, and administration |

| |of CISplatin |Tall Man lettering in pumps |

|CarBAMazepine (Tegretol®) |Similarity in generic and brand names may lead to errors |Physical separation in storage |

|OXcarbazepine (Trileptal®) |Medications have some overlapping indications | |

|Potentially Error-Prone |Potential Errors & Consequences |Error Prevention Measures |

|Drug Pairs /Groups of Drugs | | |

|CarVEDilol (Coreg®) |Similarity in generic names, indication and dosage strengths may lead |Physical separation in storage, with warning on shelf, different color |

|CapTOPril (Capoten®) |to errors |bins |

|CHLORpromazine (Thorazine®) |Similar generic names may lead to errors |Look-Alike alert decal on Omnicell lid |

|ProchlorPERazine (Compazine®) |Medications have some overlapping indications |Encourage written orders with both generic and brand names |

|ProMETHazine (Phenergan®) | | |

|EScitalopram (Lexapro®) |Similarity in generic names and indications may lead to errors |Look-Alike alert decal on Omnicell lid |

|CITalopram (CELexa®) | | |

|CloNIDine (Catapres®) |Similarity in generic names may lead to errors |Look-Alike alert decal on Omnicell lid |

|CloZAPine (Clozaril®, Fazaclo ODT®) |Medications have different indications |Preprinted order form for initial clozapine orders |

|ClonazePAM (KlonoPIN®) | |Formulary status (CloZAPine ODT is restricted) |

|Divalproex (Depakote®, Depakote Sprinkle®) |Confusion may occur between the regular release and extended release |Look-Alike alert decal on Omnicell lid |

|Divalproex Extended Release (Depakote ER®) |formulations, which may result in under/over-dosing |Pop-up in Siemens Rx system |

|Valproic Acid/Sodium Valproate (Depakene®) | |Bar code verification in all MAK units |

|DOPamine (Intropin®) |Similarity in names and strengths may lead to errors |Physical separation in storage, with warning on shelf, different colored |

|DOBUTamine (Dobutrex®) | |bins |

|DOCEtaxel (TaxoTERE®) |Similarity in generic and brand names may lead to errors |Double check process with chemotherapy audit tool for order review, |

|PACLItaxel (TaxOL®) |Interchanging these two drugs may result in serious dosing errors |compounding, and administration |

| | |Physical separation in storage, with warning on shelf, different colored |

| | |bins |

|FluPHENazine (ProLIXIN®) |Similarity in generic and brand names may lead to errors |Physical separation in storage, with warning on shelf, different colored |

|FluPHENazine Decanoate (LONG acting ProLIXIN®) |Medications have different indications |bins |

|FluOXETine (ProZAC®) | | |

|GlipiZIDE (Glucotrol®) |Similarity in names, strengths, and indications may lead to errors |Look-Alike alert decal on Omnicell lid |

|GlyBURide (Micronase®, Diabeta®,Glynase®) |GlipiZIDE = shorter acting; max dose 40 mg/day GlyBURide = longer | |

| |acting; max dose 20 mg/day | |

|Haloperidol Decanoate (LONG acting -- Haldol®) Haloperidol Lactate |Confusion may occur between the long acting and immediate release |Look-Alike alert decal on Omnicell lid |

|(SHORT acting -- Haldol®) |injectable formulation which may result in under/over-dosing | |

|Haemophilus B vaccine(Pedvax HIB®, ActHIB®, Hiberix®) |Similarities in names and reference to Haemophilus B vaccine as “HIB” |Physical separation in storage, with warning on shelf, different colored |

|Hepatitis B vaccine (Recombivax HB®, Engerix-B®) |and Hepatitis B Vaccine as “Hep B” may lead to errors |bins |

|Potentially Error-Prone |Potential Errors & Consequences |Error Prevention Measures |

|Drug Pairs /Groups of Drugs | | |

|HydrALAZINE (Apresoline®) |Similarity in generic names and strengths may lead to errors |Pop-up in Siemens Rx system |

|HydrOXYzine (Vistaril®) |Medications have different indications |Physical separation in storage, with warning on shelf, different colored |

| | |bins |

|IdaruCIZUMAB (Praxbind®) |Similarity in generic names may lead to errors |Formulary status (IDArubicin is non-formulary) |

|IDArubicin (Idamycin®) |Medications have different indications |InFLIXimab restricted to Rheumatology & GI use |

|InFLIXimab (Remicade®) | |Double check process with chemotherapy audit tool for order review, |

| | |compounding, and administration |

| | |Physical separation in storage |

|Insulin Glargine (Lantus®) long-acting basal |Similarity in names, strengths and concentration ratios may lead to |Look-Alike alert decal on Omnicell lid |

|Insulin Lispro (HumaLOG®) rapid-acting |errors |Formulary status (Insulin glargine and aspart are restricted, insulin |

|Insulin Aspart (NovoLOG®) rapid-acting | |lispro is non-formulary) |

|Insulin Regular (HumuLIN R®, NovoLIN R®) | |On High Alert Medication List, requiring two independent double checks |

|Insulin 70/30 products (NovoLIN 70/30®, NovoLOG Mix 70/30®) | | |

|KadCYLA® (ado-trastuzumab emtansine) |Similarity in brand names may lead to errors |Double check process with chemotherapy audit tool for order review, |

|KyPROLIS® (carfilzomib) |Interchanging these two drugs may result in serious dosing errors |compounding, and administration |

|LamiVUDine (Epivir®) |Similarity in generic and brand names and strengths may lead to errors |Look-Alike alert decal on Omnicell lid |

|LamoTRIgine (LaMICtal®) |Consequences of errors may include Stevens-Johnson syndrome | |

|Terbinafine (LamISIL®) |(lamotrigine) | |

| |Medications have different indications | |

|MetFORMIN (Glucophage®) |Similarity in names and strengths may lead to errors. |Look-Alike alert decal on Omnicell lid |

|MetroNIDAZOLE (Flagyl®) |Medications have different indications | |

|NiCARdipine (Cardene®) |Similarity in generic names may lead to errors |NiCARdipine is restricted to use by Anesthesia, Neurology, and |

|NiMODipine (Nymalize®) |Medications have some overlapping indications |Neurosurgery |

|NIFEdipine (Procardia®) | |Physical separation in storage |

|NORepinephrine (Levophed®) |Similar generic names and indications may lead to errors |Encourage written and verbal communication with both generic and brand |

|PHENYLephrine (Neosynephrine®) | |names |

|PredniSONE |Similar generic names may lead to errors |Physical separation in storage |

|PrednisoLONE |Medications have different indications | |

|Primidone | | |

|Potentially Error-Prone |Potential Errors & Consequences |Error Prevention Measures |

|Drug Pairs /Groups of Drugs | | |

|PHENobarbital (Luminal®) |Similarity in generic names and indications may lead to errors |PENTobarbital is restricted to use in the ICU and OR |

|PENTobarbital (Nembutal®) | |Physical separation in storage |

|RifAMPin (Rifadin®) |Similarity in generic names may lead to errors |Physical separation in storage |

|RifAXImin (Xifaxin®) |Medications have different indications | |

|RisperiDONE (RisperDAL®) |Similarity in generic and brand names may lead to errors |Physical separation in storage, with warning on shelf, different colored |

|ROPINIRole (Requip®) |Medications have different indications |bins |

|SulfaSALAzine (Azulfidine®, Sulfazine®) |Similarity in names may lead to errors |Encourage writing indications with medication orders |

|SulfaDIAzine |Medications have different indications | |

|Tdap (Boostrix®, Adacel®) |Similarity in names, strengths and concentration ratios may lead to |Product information posters showing which |

|DTaP (Infanrix®) |errors. |one is for which age group |

| |Tdap = adults; DTaP = children 6 weeks to ................
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