What should I do with Look-Alike-Sound-Alike medications, is one of the common questions I get from facilities. Having a policy and procedure for addressing this patient safety risk is an absolute necessity. Do you know what to include in your policy and what steps you should take to help reduce the risk of these medications being used in error? In this post we will show you some examples and provide some tips on how to safely handle look-alike-sound-alike medications (confused drug names).

The danger of look-alike-sound-alike medications seems obvious…they either look-alike or the sound similar right? Yes, but there’s more!  Medications can look or sound-alike in many different ways. It could be in the way the name looks on paper, such as with dopamine and dobutamine. A quick glance might lead us to reading it incorrectly. Maybe they sound similar when said aloud like Prozac and Prilosec. These issues are the most obvious and can lead to serious errors, that can result in patient harm or even death.

Not all the examples are as obvious though. Below are a couple of examples of look-alike-sound-alike dangers completely unrelated to the drug name. In both cases we have completely different medications with names that do not sound or look alike…so how is this a look-alike-sound-alike risk? It’s because despite the medications being different, the vials are very similar in many ways and can be confused and used in error.

In the first example we have vials of dexamethasone, a corticosteroid, right next to vials of glycopyrrolate, an anticholinergic medication which is commonly used to reverse bradycardia intraoperatively. Although the drug names don’t look or sound similar, the vials are very similar in size, color and markings. Also note that not all the glycopyrrolate vials are the same color…another potential concern and reason to not choose medications based on vial or cap color.

In the second example, we have a similar situation. This one was sent to me by a friend and colleague who is an excellent anesthesiologist.

This example portrays a slightly worse situation because we have different medications whose vials look-alike stored in the same compartment. The picture shows a compartment that contains ondansetron, an antiemetic used to control nausea, right next to Pitocin, a hormone that is often used to induce labor or control bleeding. Medications should always be stored separately, but especially when they are prone to error, such as in this case where the vials look very similar and could easily be selected incorrectly.

How to handle look-alike-sound-alike medications (confused drug names):

1. As I previously mentioned, the first step is having a policy that addresses how look-alike-sound-alike medications will be handled in your facility. This is an expectation of licensing and accrediting organizations such as the Centers for Medicare and Medicaid Services (CMS), Accreditation Association for Ambulatory Health Care (AAAHC), The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) and The Joint Commission (TJC). Be specific about how they will be tracked and labeled to ensure all the appropriate steps are taken to mitigate the risks. Your pharmacy consultant should be expert in this area and should be able to help you write your policy. As part of our services, we provide or help develop policies for our facilities. If you don’t have a policy and aren’t working with someone who can help you, don’t hesitate to reach out to us.
2. Having a policy is not enough. You need to ensure ongoing education of your staff to allow for consistency in practice so that everyone is on the same page. A policy without follow-through or compliance is just a piece of paper.
3. Post the list of look-alike-sound-alike medications in your facility. You can use the comprehensive list provided by the Institute for Safe Medication Practices (ISMP) as your starting point. Compare it to your formulary and develop a list that is specific to your facility. We provide a customizable list to each of our facilities and update it annually. If you need help with creating one, let us know and we can assist.
4. Consider minimizing the availability of multiple strengths in your facility. This is often a source of confusion and leads to more errors, including calculation mistakes. When buying new products, take a look at the packaging and to the extent possible, avoid buying medications with similar packaging. This is sometimes easier said than done, but most drug distributors have images up on their website to allow you to view them before buying.
5. Use Tall Man lettering when labeling medications. In the example above with dobutamine and dopamine, they would be written as “DOBUTamine” and “DOPamine”. This is the practice of highlighting the dissimilar parts of the name to distinguish them from other look-alike-sound-alike name.
6. Use labels to highlight medications with look-alike-sound-alike names. This should be included in your policy and then followed by everyone in the facility to ensure new additions are properly labeled.
7. Finally, when administering all medications, but especially look-alike-sound-alike medications, read the labels carefully while selecting and prior to administering. This is likely the last opportunity to avoid an error before the patient receives the medication.

Dealing with look-alike-sound-alike medications can seem like a daunting task and is a non-stop process. As is often the case, the best way to deal with a complex process is to start with small steps and address items one by one. Don’t go at it alone…this is one of the many examples of why you should have an expert pharmacy consultant on your team. A good consultant pharmacist can take a seemingly overwhelming task and do the majority of the legwork off your hands. In the end, you lessen your workload, make your patients safer, surveyors happier and as a byproduct, reduce your liability and costs.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies. We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.