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Three ways to identify look-alike, sound-alike drugs

Pharmacy Regulation Resource, July 14, 2004

Revisions to National Patient Safety Goal #3 require you to identify a list of look-alike and sound-alike drugs used in your organization and prevent errors that may occur from confusing these drugs. Check out three ideas from your colleagues to solve the look-alike, sound-alike drug problem.

1. Red alert
Red bins keep pharmacy staff on the lookout for potential drug mix-ups at Warren Hospital in Phillipsburg, NJ. The colored bins that dot the pharmacy shelves alert staff to double-check any medication that may look or sound like another drug, says Priti Merchant, PharmD, the hospital's clinical pharmacy coordinator.

2. Make them visible
Use current data and resources to create posters you can hang throughout your organization to remind staff about the potential for confusion, says John Santell, MS, RPh, U.S. Pharmacopeia's director of educational program initiatives. USP Quality Review #79, published in April, contained a list of almost 800 pairs of drugs with similar looking or sounding names.

3. Use tall-man lettering
Warren Hospital pharmacy staff label the red bins with tall-man lettering, Merchant says. Tall-man lettering involves capitalizing certain letters in drug names to differentiate between similar-looking and -sounding drugs.

For example, the Institute for Safe Medication Practices recommends the following spellings to identify these two drugs:

• PredniSONE
• PrednisoLONE

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