What's in a name? Ways to prevent
dispensing errors linked to name confusion
From the June 12, 2002 issue
Not a week goes by that we don't hear about confusion between
two products with similar names. For example, this week we learned
about a handwritten order for the bronchodilator FORADIL
(formoterol) that initially was misinterpreted as TORADOL
(ketorolac). In another case, a hospitalized patient reported
taking "Plaxil" at home, but she was actually taking
PLAVIX (clopidogrel). The admitting physician misinterpreted
"Plaxil" as PAXIL (paroxetine) and prescribed
this medication for the patient, which caused several days of
severe disorientation. With so many different products on the
market, it's no wonder that clinicians and patients consistently
report confusion. While manufacturers have an obligation to
review new trademarks for error potential before use, there
are some things that practitioners can do to help prevent errors
with products that have look or sound-alike names.
- Look for the possibility of name confusion when adding
a new product to the formulary. Have a few clinicians handwrite
the product name and directions as they would appear in
a typical order. Ask frontline nurses, pharmacists, technicians,
unit secretaries and physicians to view the samples of the
written product name and pronounce it to determine if it
looks or sounds like any other product or medical term.
It may be helpful to have clinicians first look at the scripted
product name to determine how they would interpret it before
the actual product name is provided to them for pronunciation.
Once the product name is known, clinicians may be less likely
to see more familiar product names in the written samples.
If the potential for confusion with other products is identified,
take steps to avoid errors as listed below.
- Prescriptions should clearly specify the dosage form,
drug strength, and complete directions. Include the product's
indication on all outpatient prescriptions and on inpatient
prn orders. With name pairs known to be problematic, reduce
the potential for confusion by writing prescriptions using
both the brand and generic name. Listing both names on medication
administration records and automated dispensing cabinet
computer screens also may be helpful. Whenever possible,
determine the purpose of the medication before dispensing
or administering it. Many products with look or sound-alike
names are used for different purposes.
- Accept verbal or telephone orders only when truly necessary.
Encourage staff to repeat back all orders, spell the product
name, and state its indication.
- When feasible, use magnifying lenses and copyholders under
good lighting to keep prescriptions and orders at eye level
during transcription to improve the likelihood of proper
interpretation of look-alike product names.
- Change the appearance of look-alike product names on computer
screens, pharmacy and nursing unit shelf labels and bins
(including automated dispensing cabinets), pharmacy product
labels, and medication administration records by highlighting,
through bold face, color, and/or tall man letters, the parts
of the names that are different (e.g., hydrOXYzine,
- Install a computerized reminder (also placed on automated
dispensing cabinet screens) for the most serious confusing
name pairs so that an alert is generated when entering prescriptions
for either drug. If possible, make the reminder auditory
as well as visual.
- Affix "name alert" stickers to areas where look
or sound-alike products are stored (available from pharmacy
- Store products with look or sound-alike names in different
locations. Avoid storing both products in the fast-mover
area. Use a shelf sticker to help locate the product that
- Continue to employ at least two independent checks in
the dispensing process (one person interprets and enters
the prescription into the computer and another reviews the
printed label against the original prescription and the
product). Research shows that individuals who are detailed
oriented (see the trees through the forest) may be able
to detect name mix-ups more easily during the final verification
process than people whose skills are more oriented to seeing
the big picture (see the forest, not just the trees).
- Open the prescription bottle or the unit dose package
in front of the patient to confirm the expected appearance
and review the indication. Caution patients about error
potential when taking products that have a look-alike or
sound-alike counterpart. Take the time to fully investigate
the situation if a patient states he is taking a medication
which is unknown (such as "Plavix" in the example
- Encourage reporting of errors and potentially hazardous
conditions with look and sound-alike product names and use
the information to establish priorities for error reduction.
Also maintain awareness of problematic product names and
error prevention recommendations provided by ISMP
and also listed on the quarterly Action Agenda), FDA (www.fda.gov),
and USP (www.usp.org).