Look Alike & Sound Alike Drugs

[Pages:5]Look Alike & Sound Alike Drugs

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

Medication Ordering PRINT clearly DO NOT ABBREVIATE drug name Write both GENERIC and BRAND names Write INDICATION for use

Distinguishing Medications By: Purchase DIFFERENT BRAND Store in SEPARATE areas DISTINGUISH names

TALL MAN lettering Circle/highlight/underline differences

Medication Administration/Storage: DOUBLE CHECK against order and MAR before

administration HIGH ALERT meds require independent double

checks Physical separation in storage (with warning on

shelf, different color bins)

POTENTIALLY ERROR-PRONE DRUG PAIRS /GROUPS OF DRUGS

POTENTIAL ERRORS & CONSEQUENCES

ERROR PREVENTION MEASURES

Acetazolamide (DiaMOX?)

Similarity in generic and brand names may

Physical separation in storage

Chlorothiazide (DiuRIL?)

lead to errors

1

Medications have the same indication

AmiloRIDE (Midamor?)

Similarity in generic names, dosage strengths, Physical separation in storage

AmlodiPINE (Norvasc?)

and dosing may lead to errors

Medications have some overlapping

indications

Amphotericin B (Fungizone?)

Confusion may occur between conventional Liposomal formulation requires ID approval

Amphotericin B ? Liposomal (AmBisome?,

and liposomal formulations; products are NOT

Amphotec?)

INTERCHANGEABLE

BuPROPion Sustained Release (Wellbutrin SR?, Similarity in generic names may lead to errors Wellbutrin XL is on formulary, Wellbutrin SR is

Zyban?)

Both BuPROPions come in 150mg tablets but

non-formulary

BuPROPion Extended Release (Wellbutrin XL?)

can be dosed either twice daily (SR) or once Formulary status (bupreNORphine;

BupreNORphine (Subutex?)

daily (XL).

bupreNORphine/naloxone are both formulary

BupreNORphine/naloxone (Suboxone?) BusPIRone (Buspar?)

These medications have different indications

with restrictions)

(Rev Feb 2018 Admin Policies 16.31 Appendix D, 16.30 Appendix A)

POTENTIALLY ERROR-PRONE DRUG PAIRS /GROUPS OF DRUGS

CARBOplatin (Paraplatin?) CISplatin (Platinol?)

CarBAMazepine (Tegretol?) OXcarbazepine (Trileptal?)

CarVEDilol (Coreg?) CapTOPril (Capoten?) CHLORpromazine (Thorazine?) ProchlorPERazine (Compazine?) ProMETHazine (Phenergan?) EScitalopram (Lexapro?) CITalopram (CELexa?) CloNIDine (Catapres?) CloZAPine (Clozaril?, Fazaclo ODT?) ClonazePAM (KlonoPIN?)

Divalproex (Depakote?, Depakote Sprinkle?) Divalproex Extended Release (Depakote ER?) Valproic Acid/Sodium Valproate (Depakene?) DOPamine (Intropin?) DOBUTamine (Dobutrex?) DOCEtaxel (TaxoTERE?) PACLItaxel (TaxOL?)

POTENTIAL ERRORS & CONSEQUENCES

ERROR PREVENTION MEASURES

Similarity in generic names may lead to errors Double check process with chemotherapy audit

Doses appropriate for CARBOplatin usually

tool for order review, compounding, and

exceed the maximum safe dose of CISplatin

administration

Tall Man lettering in pumps

Similarity in generic and brand names may

Physical separation in storage

lead to errors

Medications have some overlapping

indications

Similarity in generic names, indication and

Physical separation in storage, with warning on

dosage strengths may lead to errors

shelf, different color bins

Similar generic names may lead to errors

Look-Alike alert decal on Omnicell lid

Medications have some overlapping

Encourage written orders with both generic and

indications

brand names

Similarity in generic names and indications

Look-Alike alert decal on Omnicell lid

may lead to errors

Similarity in generic names may lead to errors Look-Alike alert decal on Omnicell lid

2

Medications have different indications

Preprinted order form for initial clozapine

orders

Formulary status (CloZAPine ODT is restricted)

Confusion may occur between the regular

Look-Alike alert decal on Omnicell lid

release and extended release formulations, Pop-up in Siemens Rx system

which may result in under/over-dosing

Bar code verification in all MAK units

Similarity in names and strengths may lead to Physical separation in storage, with warning on

errors

shelf, different colored bins

Similarity in generic and brand names may

Double check process with chemotherapy audit

lead to errors

tool for order review, compounding, and

Interchanging these two drugs may result in

administration

serious dosing errors

Physical separation in storage, with warning on

shelf, different colored bins

(Rev Feb 2018 Admin Policies 16.31 Appendix D, 16.30 Appendix A)

POTENTIALLY ERROR-PRONE DRUG PAIRS /GROUPS OF DRUGS

POTENTIAL ERRORS & CONSEQUENCES

ERROR PREVENTION MEASURES

DOXOrubicin (conventional) (Adriamycin?)

Similarity in generic and brand names may

Double check process with chemotherapy audit

DOXOrubicin (liposomal) (Doxil?, Lipodox 50?)

lead to errors Interchanging these two drugs may result in

serious dosing errors

tool for order review, compounding, and administration Physical separation in storage, with warning on shelf, different colored bins

FluPHENazine (ProLIXIN?)

Similarity in generic and brand names may

Physical separation in storage, with warning on

FluPHENazine Decanoate (LONG acting

lead to errors

shelf, different colored bins

ProLIXIN?)

Medications have different indications

FluOXETine (ProZAC?)

GlipiZIDE (Glucotrol?)

Similarity in names, strengths, and indications Look-Alike alert decal on Omnicell lid

GlyBURide (Micronase?, Diabeta?,Glynase?)

may lead to errors

GlipiZIDE = shorter acting; max dose 40 mg/day

GlyBURide = longer acting; max dose 20 mg/day

Haloperidol Decanoate (LONG acting -- Haldol?) Confusion may occur between the long acting Look-Alike alert decal on Omnicell lid

Haloperidol Lactate (SHORT acting -- Haldol?)

and immediate release injectable formulation

which may result in under/over-dosing

3

Haemophilus B vaccine(Pedvax HIB?, ActHIB?, Similarities in names and reference to

Physical separation in storage, with warning on

Hiberix?)

Haemophilus B vaccine as "HIB" and Hepatitis

shelf, different colored bins

Hepatitis B vaccine (Recombivax HB?, Engerix-B?)

B Vaccine as "Hep B" may lead to errors

HydrALAZINE (Apresoline?)

Similarity in generic names and strengths may Pop-up in Siemens Rx system

HydrOXYzine (Vistaril?)

lead to errors

Physical separation in storage, with warning on

Medications have different indications

shelf, different colored bins

IdaruCIZUMAB (Praxbind?) IDArubicin (Idamycin?) InFLIXimab (Remicade?) RiTUXimab (Rituxan?)

Similarity in generic names may lead to errors Medications have different indications

Formulary status (IDArubicin is non-formulary) InFLIXimab restricted to Rheumatology & GI use Double check process with chemotherapy audit

tool for order review, compounding, and administration Physical separation in storage

(Rev Feb 2018 Admin Policies 16.31 Appendix D, 16.30 Appendix A)

POTENTIALLY ERROR-PRONE DRUG PAIRS /GROUPS OF DRUGS

Insulin Glargine (Lantus?) long-acting basal Insulin Lispro (HumaLOG?) rapid-acting Insulin Aspart (NovoLOG?) rapid-acting Insulin Regular (HumuLIN R?, NovoLIN R?) Insulin 70/30 products (NovoLIN 70/30?, NovoLOG Mix 70/30?) KadCYLA? (ado-trastuzumab emtansine) KyPROLIS? (carfilzomib)

LamiVUDine (Epivir?) LamoTRIgine (LaMICtal?) Terbinafine (LamISIL?) Labetalol (Trandate?)

LevoFLOXacin (Levaquin?) Levothyroxine (Synthroid?) LevETIRAcetam (Keppra?) MetFORMIN (Glucophage?) MetroNIDAZOLE (Flagyl?)

NiCARdipine (Cardene?) NiMODipine (Nymalize?) NIFEdipine (Procardia?) NORepinephrine (Levophed?) PHENYLephrine (Neosynephrine?) EPINEPHrine (Adrenalin?) EPHEDrine (Akovaz?) PredniSONE PrednisoLONE PHENobarbital (Luminal?) PENTobarbital (Nembutal?) RifAMPin (Rifadin?) RifAXImin (Xifaxin?)

POTENTIAL ERRORS & CONSEQUENCES

Similarity in names, strengths and concentration ratios may lead to errors

ERROR PREVENTION MEASURES

Look-Alike alert decal on Omnicell lid Formulary status (Insulin glargine and aspart

are restricted, insulin lispro is non-formulary) On High Alert Medication List, requiring two

independent double checks

Similarity in brand names may lead to errors Double check process with chemotherapy audit

Interchanging these two drugs may result in

tool for order review, compounding, and

serious dosing errors

administration

Similarity in generic and brand names and

Look-Alike alert decal on Omnicell lid

strengths may lead to errors

Consequences of errors may include Stevens-

Johnson syndrome (lamotrigine)

Medications have different indications

Similarity in generic names have lead to errors Look-Alike alert decal on Omnicell lid

Medications have different indications

4

Similarity in names and strengths may lead to errors

Medications have different indications Similarity in generic names may lead to errors Medications have some overlapping

indications Similar generic names and indications may

lead to errors

Look-Alike alert decal on Omnicell lid

NiCARdipine is restricted to use by Anesthesia, Neurology, and Neurosurgery

Physical separation in storage Encourage written and verbal communication

with both generic and brand names

Similar generic names and indications may lead to errors

Similarity in generic names and indications may lead to errors

Similarity in generic names may lead to errors Medications have different indications

Physical separation in storage

PENTobarbital is restricted to use in the ICU/OR Physical separation in storage Physical separation in storage

(Rev Feb 2018 Admin Policies 16.31 Appendix D, 16.30 Appendix A)

POTENTIALLY ERROR-PRONE DRUG PAIRS /GROUPS OF DRUGS

POTENTIAL ERRORS & CONSEQUENCES

ERROR PREVENTION MEASURES

RisperiDONE (RisperDAL?)

Similarity in generic and brand names may

Physical separation in storage, with warning on

ROPINIRole (Requip?)

lead to errors

shelf, different colored bins

Medications have different indications

SulfaSALAzine (Azulfidine?, Sulfazine?)

Similarity in names may lead to errors

Encourage writing indications with medication

SulfaDIAzine

Medications have different indications

orders

Tacrolimus (Prograf?, Astagraf XL?)

? Similarity in names may lead to errors

? Encourage writing indications with medication

Tamsulosin (Flomax?)

? Medications have different indications

orders

Tdap (Boostrix?, Adacel?)

Similarity in names, strengths and

Product information posters showing which

DTaP (Infanrix?)

concentration ratios may lead to errors.

one is for which age group

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

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download