Confusing Names

ISMP’s List of Confused Drug Names Listed below are drug names (first column) that have sometimes been confused with other drug names (second column). Many of these were actual mix-ups that led to patients receiving the wrong drug. All of these names were contained in reports sent by health professionals and consumers to the Institute for Safe Medication Practices’ Medication Errors Reporting Program.

With the large number of drugs on the market today, the potential for medicines to have a name that looks or sounds like another medicine is high. For this reason, most drug companies test the brand names they plan to use for new medicines. They contract with companies that get working nurses, pharmacists, and doctors to look at handwritten prescriptions of the medicine to see if it looks like another medicine. This process leads to fewer medicines with look-alike names. Still, there are a lot of medicines on the market with similar names.

Doctors who include the reason you are taking the medicine on the prescription can help pharmacists avoid these kinds of mistakes. Most medicines with look-alike names are not used to treat the same condition. So, having your doctor list the reason for the medicine alerts the pharmacist to your condition and serves as a check to make sure the correct medicine is provided. But if a mix-up happens, reading the drug information leaflet that comes with your medicine can help you notice the error right away. Electronic prescriptions that doctors enter into a computer produce legible prescriptions that are less likely to be misread. But only 10% of doctors send prescriptions to pharmacies using a computer.

You can help prevent errors by:

• Asking your doctor to list the reason for the medicine on the prescription

• Making sure the pharmacist knows the reason you are taking a medicine

• Inspecting the medicine before you leave the pharmacy to be sure it looks as expected if you are refilling a prescription

• Talking to a pharmacist about the medicine when picking up a new prescription

• Reading the drug information leaflet that comes with your medicine 

by

Akshaya Srikanth

Pharm.D Internee