Medications: They are alike and they’re trouble

Keeping sound-alike medicines apart

It seems that a new prescription medication enters the market every day. With so many hitting the pharmacy shelves, pharmaceutical companies are running short of innovative names. Confusion over similar drug names, either written or spoken, accounts for approximately 15% of all reports to the U.S. Pharmacopoeia (USP) Medication Errors Reporting program, notes a recent issue of the Joint Commission on Accreditation of Healthcare Organizations’ Sentinel Event Alert.

Not only does this pose a problem for physicians and pharmacists who must decipher handwriting and a host of abbreviations when filling an order, but it can lead to disastrous consequences if the incorrect medication is administered or the correct medication is administered incorrectly. A prime example, says Matt Grissinger, safe medication management fellow with the Institute for Safe Medication Practices in Huntingdon Valley, PA, is the confusion that can result from such seemingly easily distinguishable medications as Coumadin (warfarin), for people with a history of strokes, and Avandia (rosiglitazone), a new medication for type 2 diabetes mellitus, when they are handwritten.

An issue of ISMP Medication Safety Alert! (1999; 4:1) reports an incident of a pharmacy technician misreading a prescription for Avandia 4 mg and instead filling the prescription for Coumadin 4 mg. Both a nurse and a pharmacist who had just filled three Coumadin prescriptions reviewed the initial order, and both read Coumadin. The patient received one dose of Coumadin before the error was discovered by the prescribing physician during a routine review of the patient’s medication administration chart.

Says Grissinger, "When the two medications are typewritten, they’re not alike at all, but still we get reports of this type of thing happening. The key thing from a nursing standpoint is to make sure that every medication the person is taking has an appropriate indication. When a nurse visits a patient, she should sit down and go over the meds and look to see if they are diagnosis-appropriate. If there are any questions, then the nurse should talk to the pharmacist to make sure the medication is diagnosis-appropriate. For example, if the nurse sees a patient is taking Coumadin, then they should double-check that the person has a history of strokes, or if it’s Avandia that the person is in fact diabetic."

Many times, he says, patients simply go to a retail pharmacy, pick up their prescription, pay their bill, and go home without asking any questions. "This is especially true with the elderly," he notes, "because they’re often afraid to ask questions. It’s up to the nurses then to act as the checkpoint down the road. The nurse should encourage patients and family caregivers to ask questions of the pharmacist.

"A good pharmacy will take a moment with the patient to check that the right pill is in the right vial. Have them take the pill out of the vial and show the patient or caregiver the pill, especially if it’s a refill, so the patients can see for themselves if it’s the same. It’s important to teach patients to get the interaction going — it only takes a minute."

Among Grissinger’s other tips for keeping medications in order:

Beware the medicine cabinet. "Everyone thinks you should store meds in medicine cabinets, but in reality, the bathroom temperature and humidity are not always good for medications, especially capsules and tablets," he points out. Instead, consider storing them on a table or countertop (out of the reach of children) in another room. Inclement conditions aren’t the only threats to proper medication administration, though. Grissinger says he has heard of cases where an ointment used for angina was mistaken for toothpaste.

Throw them out. "If a patient isn’t on the medication any more, we recommend that they throw the medication out," he says. "We know that pills are expensive and that people don’t want to do this, so we suggest that nurses take the pills and put them someplace where they won’t get mixed in with medications currently in use." That advice only goes so far, though, because Grissinger and the ISMP advocate throwing out anything that’s more than 2 years old or that’s past its expiration date.

Don’t mix and match. While different medications might be used toward the same end, such as pain relief, they are not interchangeable. "When I was a Joint Commission surveyor, I ran across a case where the husband was down to one pain pill. When I asked if he had a prescription waiting, his wife chimed in to say that he could always take some of hers," says Grissinger. Needless to say, this is a no-no, and home care nurses should be sure to teach family members that medications are prescribed for specific purposes and given within the context of other prescriptions and possible interactions.

Home health dispensary. If patients are in the habit of moving their medications to a weekly or monthly dispenser, home health nurses should be the one to fill them. "That way, the nurses can assess what the patient is taking and how much. This is especially important if there is a change in therapy and a medication at 80 mg drops down to 40 mg. The nurse can make sure that the change has been made in the dispensers that it has been made correctly. In these cases, don’t rely on the patient," says Grissinger.

Ask questions. When in doubt, Grissinger says, ask the pharmacist. "Don’t be afraid to ask the pharmacist to put an indication of use on the vial so the patient can see what it’s for."

To keep medication errors at bay, the ISMP has published guidelines for clinicians to use. (To see excerpt from guidelines, click here.) The group also offers a medication safety self-assessment on its web site, as well as patient alert information and a chance to report medication errors confidentially. The institute’s web address is

Also available to health care organizations interested in preventing potentially life-threatening medication errors is "Use Caution, Avoid Confusion," an updated list highlighting hundreds of confusing drug name sets and identifying more than 750 unique drug names that have been reported to the Medication Errors Reporting program. For a quick reference card or poster, interested home care agencies should contact USP’s Practitioner and Product Experience department at (800) 487-7776, or visit

[For more information, contact: Matt Grissinger, Safe Medication Management Fellow, Institute for Safe Medication Practices, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 10996. Telephone: (215) 947-7797.]