What do hydroxyzine and hydralazine have in common? Because their names sound the same, there is a chance the antihistamine could be switched for the antihypertensive agent, leading to a serious adverse drug event.

During the past seven years, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has worked to reduce the errors associated with look-alike/sound-alike drugs.

“The issue in terms of look-alike/sound-alike drugs is that this is a very common source of medication errors,” said Dr. Geoffrey Rake, M.D., director of the Department of Defense Patient Safety Center at the Armed Forces Institute of Pathology in Silver Spring, Md.

While pharmaceutical firms and the U.S. Food and Drug Administration work to reduce the likelihood of mix-ups associated with look-alike or sound-alike drugs, this type of error still occurs—sometimes with tragic results. According to a study by the Institute of Medicine, Preventing Medication Errors, there are at least 1.5 million preventable adverse drug events in the United States each year.

For 2006-2007, JCAHO updated the drugs that hospitals and other health care organizations must pick from for their organization’s look-alike/sound-alike list.

New this year for critical access hospitals, hospitals and office-based surgery are:

• Hydroxyzine and hydralazine
• Metformin and metronidazole
• OxyContin® and oxycodone

For ambulatory care, assisted living, behavioral health care, disease-specific care, home care and long-term care, newly
added drugs include:

• Lorazepam and alprazolam
• Metformin and metronidazole
• Topamax® and Toprol XL®

• Clearly specify dosage form, drug strength and complete directions on prescriptions.
• Reduce the potential for confusion by writing prescriptions using both the brand and generic name.
• Include the purpose of the medication on the prescription (often look-or sound-alike drugs are used for different
  purposes).
• Alert patients to potential mix-ups, especially with problematic drug names, and insist on pharmacy counseling
  when picking up outpatient prescriptions.
• Encourage inpatients to question nurses about medications that are unfamiliar or look or sound different than expected.
• Give verbal or telephone orders only when necessary.Orders for chemotherapeutics should never be given over
  the telephone. Include the intended purpose for clarity and encourage your staff to read back all orders, including the
  drug’s spelling and indication.

For more information on look-alike/sound-alike medications and complete lists of the medications at risk, go to the JCAHO Web site at www.jointcommission.org/  PatientSafety/NationalPatientSafetyGoals, look under “2007 Resources” and select “Look-alike/Sound-alike drug list Updated for 2006-07.”

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Created: June 14, 2007