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Microsoft word - sound alike look alike- guideline 2010.doc

Community Mental Health for Central Michigan PROTOCOL FOR LOOK-ALIKE AND SOUND-ALIKE DRUGS
This protocol should be posted in all licensed residential group homes who contract with
Community Mental Health for Central Michigan
ADMINISTRATIVE GUIDELINE

In an effort to improve medication safety and to meet The Joint Commission’s National Patient Safety Goal
Number 3, Community Mental Health for Central Michigan (CMHCM) has identified a process to address
sound-alike and look-alike drugs. The Performance Improvement Team that developed this guideline will
continue to monitor new drugs on the market as they are released, review the list included with this guideline
on an annual basis, and provide appropriate updates. Appropriate action to prevent errors involving the
interchange of these drugs will be taken.
Each CMHCM site (including direct and provider network sites) where medication is distributed or
administered will post the attached lists and implement a plan for preventing drug mix-ups. This plan may
consist of but not be limited to:
Š Listing both the brand and generic names on medication records. Š Storing products with look-alike or sound-alike names in different locations. Š Employing double checks in the distribution process. Š Affixing “name alert” stickers to areas where look-alike or sound-alike products are stored. Š Changing the appearance of look-alike product names on pharmacy labels, computer screens, shelf labels and bins, and medication records by highlighting, through bold face, color, and/or tall man
letters, the parts of the names that are different (e.g. hydrOXYzine, hydrALAzine).
Š Having physicians write prescriptions using both the brand and generic names. Š Alerting consumers to the potential for mix-ups. Š Encouraging patients and direct care staff to question pharmacists and nurses about medications that are unfamiliar or look or sound different than expected. Community Mental Health for Central Michigan PROTOCOL FOR LOOK-ALIKE AND SOUND-ALIKE DRUGS
Institute for Safe Medication Practices (ISMP) List of Confused Drug Names

Permission is granted to reproduce material for internal newsletters or communications with proper
attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received
through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication
errors to the MERP via the web at www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally
certified patient safety organization (PSO), providing legal protection and confidentiality for patient safety
data and error reports it receives.

This list of confused drug names, which includes look-alike and sound-alike name pairs, consists of those
name pairs that have been involved in medication errors published in the ISMP Medication Safety Alert! and
the ISMP Medication Safety Alert! Community/Ambulatory Care Edition. The errors involving these
medications were reported to ISMP through the ISMP Medication Errors Reporting Program (MERP).
This list also contains the names that appear on The Joint Commission’s list of look-alike and sound-alike
names. The Joint Commission established a National Patient Safety Goal that requires each accredited
organization to identify a list of look-alike or sound-alike drugs used in the organization. Those names that
appear on The Joint Commission’s list have been noted with an asterisk (*) below.
Drug Name
Confused Drug Name
acetaZOLAMIDE*
acetoHEXAMIDE*
acetoHEXAMIDE*
acetaZOLAMIDE*
ALPRAZolam*
LORazepam*
aMILoride
amLODIPine
Drug Name
Confused Drug Name
amLODIPine
aMILoride
Community Mental Health for Central Michigan amphotericin B* azaCITIDine
azaTHIOprine
azaTHIOprine
azaCITIDine
buPROPion
busPIRone
busPIRone
buPROPion
Drug Name
Confused Drug Name
carBAMazepine
OXcarbazepine
CARBOplatin
CISplatin
Community Mental Health for Central Michigan
ceFAZolin
cefTRIAXone
cefTRIAXone
ceFAZolin
CeleBREX*
CeleBREX*
CeleBREX*
CeleBREX*
chlordiazePOXIDE
chlorproMAZINE
chlorproMAZINE
chlordiazePOXIDE
chlorproMAZINE
chlorproPAMIDE
chlorproPAMIDE
chlorproMAZINE
CISplatin
CARBOplatin
clomiPHENE
clomiPRAMINE
clomiPRAMINE
clomiPHENE
clonazePAM
cloNIDine
clonazePAM
LORazepam
cloNIDine
clonazePAM
cloNIDine*
KlonoPIN*
cycloSERINE
cycloSPORINE
cycloSPORINE
cycloSERINE
DACTINomycin
DAPTOmycin
DAPTOmycin
DACTINomycin
Drug Name
Confused Drug Name
Darvon Diovan
DAUNOrubicin*
DAUNOrubicin citrate liposomal*
DAUNOrubicin*
DOXOrubicin*
DAUNOrubicin*
IDArubicin*
DAUNOrubicin citrate liposomal*
DAUNOrubicin*
Solu-MEDROL
Community Mental Health for Central Michigan dexmethylphenidate dimenhyDRINATE
diphenhydrAMINE
diphenhydrAMINE
dimenhyDRINATE
DOBUTamine
DOPamine
DOPamine
DOBUTamine
DOXOrubicin*
DAUNOrubicin*
DOXOrubicin*
DOXOrubicin liposomal*
DOXOrubicin*
IDArubicin*
DOXOrubicin liposomal*
DOXOrubicin*
DULoxetine
FLUoxetine
ePHEDrine*
EPINEPHrine*
Drug Name
Confused Drug Name
EPINEPHrine*
ePHEDrine*
fentaNYL
SUFentanil
FLUoxetine
PARoxetine
Community Mental Health for Central Michigan
FLUoxetine
DULoxetine
glipiZIDE
glyBURIDE
glyBURIDE
glipiZIDE
guaiFENesin
guanFACINE
guanFACINE
guaiFENesin
HMG-CoA Reductase Inhibitors ("statins") HumaLOG*
HumuLIN*
HumaLOG*
HumaLOG Mix 75/25
HumuLIN 70/30
Humapen Memoir (for use with HumaLOG)
umapen Memoir (for use with HumaLOG)
HumuLIN*
NovoLIN*
HumuLIN*
HumaLOG*
HumuLIN 70/30
HumaLOG Mix 75/25
hydrALAZINE*
hydrOXYzine*
HYDROcodone*
oxyCODONE*
hydrOXYzine
HYDROmorphone*
hydrOXYzine
Drug Name
Confused Drug Name
hydrOXYzine*
hydrALAZINE*
IDArubicin*
DAUNOrubicin*
IDArubicin*
DOXOrubicin*
inFLIXimab
riTUXimab
tuberculin purified protein derivative (PPD) Community Mental Health for Central Michigan Kaopectate (bismuth subsalcylate) KlonoPIN*
cloNIDine *
LaMICtal
LaMICtal
lamiVUDine*
lamoTRIgine*
lamoTRIgine*
lamiVUDine*
lamoTRIgine
Drug Name
Confused Drug Name
lamoTRIgine
LORazepam*
ALPRAZolam*
LORazepam
clonazePAM
LORazepam
LORazepam
Community Mental Health for Central Michigan Lyrica metFORMIN*
metroNIDAZOLE*
metroNIDAZOLE*
metFORMIN*
Drug Name
Confused Drug Name
HYDROmorphone*
morphine - non-concentrated oral liquid* morphine - non-concentrated oral liquid* OxyCONTIN*
Community Mental Health for Central Michigan Neurontin niCARdipine
NIFEdipine
NIFEdipine
niCARdipine
NIFEdipine
niMODipine
niMODipine
NIFEdipine
NovoLIN*
HumuLIN*
NovoLIN*
NovoLOG*
NovoLIN 70/30*
NovoLOG Mix 70/30*
NovoLOG*
HumaLOG*
NovoLOG*
NovoLIN*
NovoLOG FLEXPEN
NovoLOG Mix 70/30 FLEXPEN
NovoLOG Mix 70/30 FLEXPEN
NovoLOG FLEXPEN
NovoLOG Mix 70/30*
NovoLIN 70/30*
Drug Name
Confused Drug Name
HMG-CoA Reductase Inhibitors ("statins") OLANZapine
QUEtiapine
paregoric (camphorated tincture of opium)* OXcarbazepine
carBAMazepine
oxyCODONE*
HYDROcodone*
oxyCODONE*
OxyCONTIN*
OxyCONTIN*
OxyCONTIN*
oxyCODONE*
paregoric (camphorated tincture of opium)* PARoxetine
FLUoxetine
PENTobarbital
PHENobarbital
PHENobarbital
PENTobarbital
Community Mental Health for Central Michigan Platinol prednisoLONE
predniSONE
predniSONE
prednisoLONE
PriLOSEC*
Drug Name
Confused Drug Name
PriLOSEC*
QUEtiapine
OLANZapine
quiNIDine
quiNIDine
Community Mental Health for Central Michigan Ritalin SR riTUXimab
inFLIXimab
Drug Name
Confused Drug Name
SandIMMUNE
SandoSTATIN
SandoSTATIN
SandIMMUNE
SINEquan
SEROquel
SEROquel XR
SEROquel
SEROquel
SINEquan
SEROquel XR
SEROquel
SEROquel
SINEquan
SINEquan
SEROquel
SINEquan
SINEquan
SINEquan
sitaGLIPtin
SUMAtriptan
Solu-CORTEF
Solu-MEDROL
Solu-MEDROL
Solu-MEDROL
Solu-CORTEF
SUFentanil
fentaNYL
sulfADIAZINE
sulfiSOXAZOLE
sulfiSOXAZOLE
sulfADIAZINE
SUMAtriptan
sitaGLIPtin
SUMAtriptan
TEGretol
TEGretol XR
TEGretol
TEGretol
Community Mental Health for Central Michigan
TEGretol XR
TEGretol
TEGretol
Drug Name
Confused Drug Name
tuberculin purified protein derivative (PPD) tiaGABine*
tiZANidine*
tiZANidine*
tiaGABine*
TOLAZamide
TOLBUTamide
TOLBUTamide
TOLAZamide
traMADol*
traZODone*
traZODone*
traMADol*
TEGretol
tuberculin purified protein derivative (PPD) tuberculin purified protein derivative (PPD) vinBLAStine*
vinCRIStine*
vinCRIStine*
vinBLAStine*
Community Mental Health for Central Michigan Xanax* Drug Name
Confused Drug Name
ZyPREXA Zydis
ZyPREXA*
SUMAtriptan
SINEquan
ZyPREXA*
ZyPREXA*
ZyPREXA Zydis
ZyPREXA*
ZyrTEC-D
ZyrTEC (cetirizine)
ZyrTEC Itchey Eye Drops (ketotifen fumarate)
ZyrTEC-D
ZyrTEC Itchey Eye Drops (ketotifen fumarate)
ZyrTEC (cetirizine)
* These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement. Approved by ELT:

Source: http://www.zums.ac.ir/files/Treatment/pages/protocol_for_look_alike_and_sound_alike_drugs.pdf

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