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Lesson · 24 min

Medication Safety and Look-Alike Names

The name pairs that cause dispensing errors, and the checks that catch them.

By the end of this lesson you can

  • Recognize look-alike and sound-alike drug name pairs
  • Apply the checks that catch a selection error
  • Explain what tall man lettering is for
  • Respond correctly to a dispensing error
📘 Reading Lesson

Lesson Notes

Read through the key concepts before you try the challenge.

The names are genuinely similar, and that is the hazard

On the job

You are pulling stock for a prescription.

The shelf holds hydralazine and hydroxyzine beside each other. One treats high blood pressure and one is an antihistamine. The names differ by three letters, the boxes are similar, and you are on your fortieth prescription of the shift.

Your task: Learn the pairs and the checks, because attention alone does not survive a busy shift.

PairWhat they are
hydrALAZINE / hydrOXYzineAntihypertensive / antihistamine
predniSONE / predniSOLONETwo different corticosteroids
metFORMIN / metRONIDAZOLEAntidiabetic / antibiotic
clonazePAM / cloNIDineAnticonvulsant / antihypertensive
glipiZIDE / glyBURIDETwo different sulfonylureas
cycloSPORINE / cycloSERINEImmunosuppressant / antibiotic
vinBLAStine / vinCRIStineTwo chemotherapy agents — a fatal confusion
Look-alike / sound-alike pairs to know
The capital letters in that table are tall man lettering, and they are not a typographic quirk. Emphasizing the differing portion of two similar names measurably reduces selection errors, and it appears on labels, shelf tags, and ordering systems for exactly that reason. When you see it, it is telling you that this name has a dangerous twin.
CheckWhen
Read the label at the shelfBefore picking up the bottle
Read it again when countingAs the tablets go into the tray
Read it again at the point of labellingBefore the label is applied
Match the NDC number, not the nameNumbers do not look alike the way names do
Check the strength as carefully as the nameRight drug, wrong strength is equally an error
Never rely on bottle appearanceManufacturers change packaging without notice
The checks that catch a selection error
If you discover a dispensing error after the medication has left, report it immediately to the pharmacist — do not attempt to correct it yourself and do not delay while deciding how to phrase it. The patient may need to be contacted before the next dose. Pharmacies have error reporting processes precisely because errors happen to careful people, and the purpose is to fix the system rather than to blame the person. Concealing one converts a mistake into something far more serious.
Check your understanding

What is the most reliable way to confirm you have pulled the correct product?

Challenge

Apply what you've learned in this lesson.

Learn the pairs cold. This is the part of the job where errors reach patients.

  1. Find the ISMP list of confused drug names and select ten pairs relevant to a retail setting. Learn what each drug is for.
  2. For each pair, write one sentence on what would happen if a patient received the wrong one.
  3. Research tall man lettering and find three real examples of it on labels or in a formulary.
  4. Write out the steps you would take, in order, on discovering a dispensing error after the patient has left.

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