Source: Institute for Safe Medication Practices 2000. (Photos used with permission)

Dispensing or administration errors can occur due to factors such as packaging or labeling problems, which can cause mistakes in the pharmacy or on the hospital floor. In the left-hand photo, the packages for vincristine sulfate and vinblastine sulfate look very similar and could easily be mistaken for each other on a pharmacy shelf. (No events related to this packaging had been reported as of the Safety Alert publication date.2) In the right-hand photo, we see two look-alike vials of Naropin(TM) (ropivacaine HCl). If you look carefully, you can see that there's small, black printing on the clear plastic containers. The print is very hard to read, especially when held against a dark background. (A near miss with these vials was actually reported.3)

Look-alike or Sound-alike Names

Shown here are some strategies for reducing the risk of errors with drugs having names that look or sound alike.

Don't rely solely on memory
Tips for error prevention
tell the patient/caregiver what it is and why you are prescribing it
provide both generic and brand names on handwritten prescriptions
consider prescribing applications for personal digital assistants (PDAs)
computerized physician order entry (CPOE) systems
For verbal or telephone orders
spell out the name of the drug (e.g., "x" and "z" are common sound-alikes)
ask listener to repeat the drug name, dosage, and frequency -- "hear back"
Offered by Michael Cohen,4 president of the Institute for Safe Medication Practices, one recommendation is to "never rely solely on one's memory of problem name pairs." As we tend to remember things based on familiar patterns, a reliance on memory alone is an invitation for medication error.5 Tips for error prevention now also include the use of CPOE systems, although it may present new problems such as selecting the first choice in a drop down list.These systems provide interactive confirmation of the order and reminders regarding the drug's approved prescribing information. Prescribing applications for PDAs are becoming more the norm in clinical practice settings; however, if you or your practice is not using a CPOE system at present, providing both the generic and brand names on any handwritten prescription can help assure that the pharmacist will dispense the correct medication. It's also important to tell the patient or caregiver exactly what medication(s) you are prescribing and the purpose it (each) serves because this helps to avoid unintentional duplication of prescriptions.6, 7