Practitioners' Reporting News

Similar Drug Names Continue to be Reported

Issued October 23, 2003

Numerous reports have been submitted to the USP Medication Errors Reporting (MER) Program regarding similar drug names. The following are some of the products and descriptions that were identified in reports received between March – August 2003, where the brand names look alike/sound alike, brand and generic names look alike/sound alike, or generic names look alike/sound alike:

Products Involved	Therapeutic Class	Description
Advicor™ Altocor™	Antihyperlipidemic Antihyperlipidemic	Prescriber wrote a prescription for Advicor but intended to write Altocor.
DiaJect® (diazepam) injectable – pending approval Diastat® (diazepam) rectal gel	Anticonvulsant Anticonvulsant	Potential for error (wrong route) due to same active ingredient and administration via a syringe.
Levaquin® Levsin SL®	Fluoroquinolone Anticholinergic/ Antispasmodic	Verbal order for Levaquin documented as Levsin.
Sertraline Soriatane®	Antidepressant Retinoid	Prescriber wrote illegible order for Soriatane. Pharmacist entered and dispensed order as sertraline. Unit secretary and nurse also transcribed order as �serlatane� and sertraline.
Vicodin® Visicol™	Narcotic Analgesic Laxative	Prescriptions for Visicol (preprinted script in one case) filled with Vicodin. One patient noticed error by name and indication. Another patient was not so fortunate and experienced severe nausea, protracted vomiting, and hematemesis.
Tamoxifen Tamsulosin	Hormone (Antiestrogen) Antiadrenergic/ Sympatholytic	Order was written for Flomax® (tamsulosin) and faxed to the pharmacy. Pharmacy dispensed tamoxifen due to the close proximity of the two products (e.g., stored next to each other).
Topamax® Toprol-XL®	Anticonvulsant Antiadrenergic/ Sympatholytic	Prescription for Topamax was filled with Toprol XL. Patient took wrong medication for three weeks. Patient began experiencing hallucinations again.
Zebeta® Zetia™	Antiadrenergic/ Sympatholytic Antihyperlipidemic	Order for Zetia was dispensed with Zebeta. Both products are available in 10 mg, are packaged in small bottles, and may be stored next to each other if stocked by brand name. Illegible orders for Zetia may be interpreted as Zebeta, as both names contain the letters �Z,� �E,� �T,� and �A.�
Zestril® Zetia™ Zyrtec®	ACE Inhibitor Antihyperlipidemic Antihistamine	Zetia interpreted as Zyrtec or Zestril; some due to illegible handwriting and one was a verbal order. Similar letters, dose, and dosage forms may lead to a mix up.

The healthcare professional's submitting these reports made the following recommendations:

Order medication by generic name (e.g., when brand names look alike/sound alike)

Include diagnosis on prescription

Repeat verbal orders back to the prescriber and spell the name of the drug

Prescribers should discuss with patients the name of the drug, indication, and instructions for use

Pharmacists should ensure that the prescribers instructions are reinforced at patient counseling�a critical step in identifying errors

Patients should talk with the pharmacist before leaving the pharmacy, especially if it is a new drug

Advise patients to check the labels on their medications before taking them

Before administering the medication, review the name and indication with the patient if possible, and check that the patient's diagnosis matches the drug's indication

Patients should report any changes in medication appearance (e.g., size, color, smell) to their pharmacist, prescriber, and/or healthcare professional

Stock similar named products by generic name if products are stored via brand name and vice versa (e.g., separate the look-alike products)

Place stickers with �Tall Man� letters near the similar named products

Alert all staff to the potential for error and any actual errors that have occurred

Practitioners are encouraged to report similar medication errors to the USP MER Program at www.usp.org/patientSafety/mer/. Reporting forms can also be printed at that address or requested by calling 1-800-23-ERROR (1-800-233-7767).

Keep an eye out for the updated Use Caution Avoid Confusion similar names list to be released in fall 2003.

Readers are advised that official USP cautions and warnings for drugs appear in the USP–NF or USP DI. Unless otherwise indicated, any advice or opinions expressed herein reflect solely the judgment of USP staff. Such statements are intended for further consideration and evaluation and may or may not be applicable to a particular practice. The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices.