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Watch look-alike, sound-alike drugs in cart drawers

Pharmacy Regulation Resource, June 22, 2005

Taking precautions with look-alike and sound-alike drugs may seem simple in a centralized location, but it may become tricky in medication cart drawers, where space is at a premium.

JCAHO National Patient Safety Goal 3C and standard MM.2.20 require hospitals to take actions to prevent errors involving similar-looking and -sounding drugs.

Tip: Use Ziploc storage bags with warning labels to segregate look-alike and sound-alike drugs in medication cart drawers, says Doug Wong, PharmD, senior executive consultant for the Grapevine, TX-based Pharmacy Healthcare Solutions.

In addition, computer systems can warn pharmacists whenever they're dealing with a look-alike or sound-alike drug.

"When the pharmacist receives the warning, [he or she will] know to package the easily confused medication with a warning label," Wong says. "This is especially helpful in larger hospitals where multiple pharmacists are filling carts."

If your hospital lacks this technology, tailor your labels to draw more attention to the look-alike and sound-alike drugs. Wong suggests incorporating the following on the labels:

• "tall-man" lettering, such as DOPamine or DOButamine
• an indication for use
• the generic and brand name
• a bright-colored background

"You have some room to be creative here," Wong says. "The main point is that you implement something that plainly distinguishes the drug from others."

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