A medical person looking at a container of different medication bottles.
Avoiding Medication Mix-ups

Look-alike, sound-alike medications are a contributing factor in wrong drug medication errors, because the similar names are easily mixed up—presenting a high risk of patient harm. After a clinical pharmacist reported drugs with confusing names, the facility launched a look-alike drug contest, challenging pharmacy staff to identify the two medications in stock that looked the most alike. Each of the 22 contest entries was reviewed for error prevention, and those identifying manufacturer labeling issues were referred to the Institute for Safe Medication Practices (ISMP). As a result of the first contest, the facility changed purchasing practices to stock drugs with less confusing names; changed how medication is stored, to physically separate look-alikes where feasible; and revised labels prepared by the pharmacy to use inverted text and relocate key information. The contest was expanded the next year to include all hospital staff who work with medications, again followed by error reduction strategies. One of the labeling issues they reported to ISMP, concerning the look-alike pair of ephedrine and epinephrine, was published in ISMP’s newsletter and received national attention.