Confusing, look-alike, and sound-alike medications

AORN Journal,  Nov, 2007  by Suzanne C. Beyea

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The effort to provide safe patient care creates many challenges. One issue many clinicians confront every day is clearly and correctly identifying medications and solutions. This can be confusing when medications have similar names, labels, or containers. Additionally, supply-chain issues can result in substitutions, changes in suppliers or packaging, and a host of unexpected and confounding factors. For example, a label for a particular medication has always been green. The next time the vendor stocks it, however, its label has been changed to orange. The same medication may look like a different product altogether. With new products and medications being released each week, many clinicians may not be familiar with the ever-expanding list of medications or with those medications in particular that have been identified as "confusing" or that have "look-alike" or "sound-alike" names.

PUBLISHED WARNINGS

Numerous groups interested in safe medication use have addressed issues related to these problems. As early as 2001, the Joint Commission published warnings about the inherent safety issues surrounding confusing medication names. In its Sentinel Event Alert related to this topic, the Joint Commission required hospitals, ambulatory surgery centers, and behavioral health organizations to establish policies and practices aimed at reducing the high risk of errors associated with look-alike and sound-alike medications. (1) This recommendation was based in part on the identification of hundreds of confusing medications by the United States Pharmacopeia (USP). Other groups, including the US Food and Drug Administration and the Institute for Safe Medication Practices (ISMP), have addressed this issue by providing lists of confusing names and making recommendations to reduce the potential errors associated with these medications. (2-7)

Subsequently, the Joint Commission developed a National Patient Safety Goal to

   Identify and, at a minimum, annually review a list of look-alike/
   sound-alike drugs used in the organization, and take action to
   prevent errors involving the interchange of these drugs. (1)

The Joint Commission also created a list of the most problematic medications for critical-access hospitals, hospitals, and office-based surgery settings. (8) The list includes brand and generic names for medications, and it details potential errors with related consequences and recommended safety strategies. The Joint Commission also made general recommendations for preventing medication name mix-ups and provided several strategies for organizations and clinicians to employ. (8)

Other initiatives and resources also are available to health care providers to help prevent errors related to confusing medication names. The Institute for Healthcare Improvement provides a variety of tips to prevent medication name-related errors, and it provides a forum for clinicians to submit additional strategies for preventing these types of errors. (9)

The ISMP also provides regular information about this topic. In a recent newsletter, for example, the ISMP provided a list of commonly confused medication names and listed preventive strategies to be used by regulatory agencies, pharmaceutical companies, health care organizations, practitioners, and patients. (10) The ISMP monitors this issue on an ongoing basis and provides best practices for error reduction strategies.

Through its reporting systems, the USP continues to monitor the errors associated with confusing medications. In 2004, the USP reported that 31,932 reports submitted to its MED-MARX medication error-reporting database were the result of look-alike or sound-alike medications (eg, similar packaging, labeling, product names)." This report included examples of actual errors with photographs of the labels or packaging to assist clinicians in recognizing how easy it could be to misidentify a medication name or label.

FACILITY-SPECIFIC MEASURES

Despite increased awareness of look-alike and sound-alike medications, medication errors continue to occur. Furthermore, few clinicians know exactly which medications are most problematic within each specific clinical setting. For example, most hospitals and organizations maintain a general list of look-alike and sound-alike medications without further identifying specific medications common to individual clinical departments. To increase patient safety, problematic medication lists should be made more specific. For example, a list could be created that identifies medications commonly used in the OR, and a separate list could be compiled listing problematic medications used in the intensive care unit. Staying alert to the specific medications that cause the most confusion in individual practice settings can help clinicians better identify potential errors before they occur.

Perioperative clinicians need to ask, "What look-alike and sound-alike medications exist in the medication cabinet or supply room?" Mistakes may be more likely with the following medication names, labels, and/or packaging: