Simple rules for preventing sound-alike drug mix-ups


It's easier than you think to prevent sound-alike drug errors. Hint: Pay attention!

I am responding to a recent article about drug names published in the Drug Topics hospital newsletter [Hospital Pharmacist’s Report, October 6, 2011; ISMP warns of sound-alike drug names mix-up].

That’s 3 million medication errors and 100,000 unnecessary deaths. There are things we can do to reduce those numbers.

The first step is to make sure you have the correct patient. Too many names sound alike but are spelled differently, especially names with the letters C and K (e.g., Catherine/Katherine) as well as others such as Jane/Jayne, Amy/Amie, etc.

It may sound obvious, but it is also important to make sure you have the correct address, birth date, and phone number.

When the patient sees the doctor, the following questions are a must: “Will this medication interfere with my other Rx or OTC meds, vitamins, and herbal supplements?” “What are the expected side effects?” “How do I take the medication?” (Half of today’s prescriptions are written incorrectly.) “Should I take it before or after a meal/in the evening/in the afternoon?”

Most important, the directions must include what the drug is used for. Recently a young women was given a prescription for Provera 5 mg (female hormone) and received Proscar 5 mg (used for the prostate). That error would not have occurred if the label had stated the drug’s purpose.

At the pharmacy, patients should ask the pharmacist the same questions they asked the doctor, so that they’re on the same page. Patients should make sure that the drug’s use is noted on the label as part of the directions. Before leaving the pharmacy, patients should check the label to make sure the right name is on the prescription, the directions are correct, and the drug’s purpose is indicated.

Errors that have injured patients include the dispensing of Prozac 40 mg instead of Prilosec 40 mg (the patient died). OTC cetirizine and hydroxyzine (used for itching) have the common side effect of drowsiness; a patient taking both was involved in a serious car accident. And if the woman who was given Proscar instead of Provera had been pregnant, she would have delivered a child with serious birth defects.

These are just a few examples of the seriousness of what happens and could have easily been prevented. Patients have to be their own advocates.

Robert Katz has been a working pharmacist for 40 years and is still passionate about the profession. You can e-mail him at

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