Practitioners' Reporting News

JCAHO Alert Highlights USP's List of Look-alike, Sound-alike Drug Names

Issued June 14, 2001

Confusion over the similarity of drug names, when either written or spoken, accounts for approximately 15% of all reports to the USP Medication Errors Reporting (MER) Program. The USP Quality Review #76 addresses this issue of confusion between similar brand names, between similar generic names, and between similar brand and generic names. Such confusion is compounded by illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labeling, and incorrect selection of a similar name from a computerized product list.

In the May issue of its publication, Sentinel Event Alert, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) stressed that all health care organizations should review their policies and procedures regarding medication use to reduce the high potential for error from look-alike and sound-alike drugs. Organizations are recommended to evaluate medication errors as a criterion for product selection and purchase. The Joint Commission suggested strategies for minimizing risk and preventing potential errors, which include the following:

  • Do not store problem medications alphabetically by name. Store such identified medications out of order, or in an alternate location.

  • Provide or ask for both the generic and brand names of drugs for medication orders in order to provide patients and staff with information to avoid unintentional duplication.

  • Develop a policy for taking verbal or telephone orders. For example, when taking verbal drug orders, clearly repeat the name of the drug, the dosage ordered, and request or provide correct spelling. This is particularly important for sound-alike drugs. The National Coordinating Council for Medication Error Reporting and Prevention recently released comprehensive recommendations to reduce medication errors associated with verbal prescription orders. The recommendations are on the NCC MERP Web site.

  • Provide the generic and brand name on all medication labels. JCAHO standards in all programs (e.g. TX.3.5.1 in Comprehensive Accreditation Manual for Hospitals) require that all dispensed medications be appropriately and safely labeled using a standardized method in the most ready-to-administer form possible to minimize opportunities for error. This includes having both the generic name and, when different from the generic name, the brand name of the drug on the medication order. Surveyors will evaluate if the drug name on the medication order, medication label, and nursing MAR are the same.

  • Provide patients with written information about their drugs including the brand and generic names.

The JCAHO report highlighted USP's Quality Review #76, "Use Caution, Avoid Confusion," which includes hundreds of confusing drug name sets. Updated in March 2001, the name sets are compiled from reports submitted to the USP MER Program concerning drug names that either have the potential to cause medication errors or have been implicated in actual medication mix-ups.


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.