Prevent Mishaps With Look-Alike/Sound-Alike Meds

Mix-ups with look-alike/sound-alike (LASA) med pairs may be causing thousands of med errors each year.

Refresh your efforts to limit mishaps with LASA meds.

Help update your pharmacy’s LASA med list at least yearly using sources such as the ISMP website, internal error data, etc...as required by Joint Commission and pharmacy policy.

Consider including other meds that aren’t officially on ISMP’s list...but can still fool the eyes. For example, methotrexate could be confused with methIMAzole or methocarbamol.

Use strategies to prevent selection issues with LASA meds. For instance, separate similar-looking meds using dividers, plastic bins, etc...or use shelf tags or stickers to alert staff.

Inquire about ordering look-alike meds from different manufacturers. Recently, hyoscyamine SL and ODT dosage forms were confused for each other...due to nearly identical packaging.

Use safety checks (barcode scanning, NDCs, etc) with each package when filling orders...bypassing safety protocols is a recipe for disaster.

Repeat back drug names verbally. Sound-alike meds are easily confused for one another...especially over the phone.

Ask your admin about adding tall man lettering (DOBUTamine, DOPamine, etc) to systems...including automated dispensing cabinets (ADCs) and EHRs.

Stay alert for missing or unclear drug suffixes (SR, XL, etc). Confusing the abbreviation for morphine immediate-release “IR” with the extended-release “ER” abbreviation may cause a serious overdose.

Continue to double-check the full brand and generic name...and type at least 5 letters during product selection to narrow choices.

Document known indications when taking med histories. For example, adding “For blood sugar” to a metformin entry may prevent confusion with methocarbamol and other meds.

Report any mishaps or near misses with look-alike/sound-alikes to your pharmacist. They can help set up safeguards to avoid future mishaps...and improve patient safety.

Spot more culprits with our technician tutorial, Preventing Med Errors.

• Technician Tutorial: Preventing Med Errors