Reducing Medication Errors from Look-Alike, Sound-Alike Drugs
Medication safety doesn’t only depend on the right drug being prescribed. It also depends on the right drug being heard, read, entered, dispensed, and administered. That may sound obvious, but history tells us a different story. Medication name confusion has contributed to safety concerns significant enough to prompt the renaming of several well-known drugs.
Losec became Prilosec after repeated confusion with Lasix. Brintellix was renamed Trintellix to reduce mix-ups with Brilinta. And Celebrex originally launched as Celebra before concerns arose about confusion with Celexa.
Since 1975, the Institute for Safe Medication Practices (ISMP) has maintained a List of Confused Drug Names which includes medications at high risk for errors due to names that look or sound similar.
Despite advances in technology, including EMRs and electronic prescribing, LASA medications continue to challenge healthcare providers. Common examples of LASA drug names seen daily in senior living and LTC settings include:
- hydralazine vs. hydroxyzine
- acetaminophen vs. acetazolamide
- clonazepam vs. clonidine
Reducing LASA-related errors requires more than awareness alone. Effective prevention depends on standardized workflows, communication safeguards, technology optimization, and a culture of continuous quality improvement. Here are five strategies that can help senior living and LTC operators reduce the risk of medication errors from confused drug names:
1. Include the Indication on Medication Orders
For both verbal and written orders, including the reason for use can significantly reduce the risk of a medication name being misheard or misread. Adding “for anxiety,” “for blood pressure,” or “for sleep” provides an additional safety check for nurses, pharmacists, and med aides during order entry, dispensing, and administration.
This practice is particularly valuable when medications have similar names but vastly different uses. For example, hydrOXYzine prescribed for itching is much less likely to be confused with hydrALAZINE when the indication is included on the order. Likewise, cloNIDine is far less likely to be mistaken for clonazePAM when the order specifies treatment for hypertension.
2. Read Back All Verbal Orders
Verbal orders—and telephone orders in particular—increase the risk of medication miscommunication with similar-sounding drug names. Background noise, accents, interruptions, or poor phone connections can all contribute to orders being misheard or transcribed incorrectly.
Whenever possible, verbal orders should be limited to urgent or necessary situations. When verbal communication is required, make read-back a habit for all medication orders.
Read-back should include repeating all order details back to the prescriber, including:
- Drug name
- Dose
- Frequency
- Route
- Indication for use
This additional verification step creates another opportunity to catch errors before they reach the resident.
3. Limit Handwritten Orders
Electronic prescribing and integrated EHR systems have significantly reduced the use of handwritten medication orders. However, handwritten documentation and transcription still occur in many LTC settings, particularly during on-site physician rounding and external provider communications, including after-hours and on-call situations.
When handwritten documentation is necessary, use clear block printing and avoid abbreviations that may increase confusion. Illegible handwriting combined with LASA drug names creates unnecessary risk.
4. Enable Tall Man Lettering in eMAR/EHR Systems
Tall Man lettering uses selective capitalization to emphasize the differences between similar drug names. Examples include hydrALAZINE versus hydrOXYzine and risperiDONE versus rOPINIRole. The ISMP and FDA both recommend this strategy as part of broader medication safety efforts.
When available, Tall Man lettering should be enabled wherever medications are selected or viewed, including eMAR/EHR systems, pharmacy dispensing systems, and automated dispensing cabinets.
5. Educate Staff on High-Risk LASA Medications
Staff education should focus on the medications most commonly encountered within the community. For senior living and LTC settings, commonly used LASA medications include:
- aMILoride vs. amLODIPine
- risperiDONE vs. rOPINIRole
- clonazePAM vs. cloNIDine
- oxyCODONE vs. oxyMORphone
- traMADol vs. traZODone
- metFORMIN vs. metroNIDAZOLE
- CeleXA vs. ZyPREXA
- prednisoLONE vs. predniSONE
Education should be ongoing and incorporated into medication administration training and competency evaluations for anyone involved in medication ordering, dispensing, or administration. Communities may also consider using visual reminders such as reference sheets in medication rooms, shift huddle reminders, and focused follow-up education after medication errors or near misses involving LASA medications.
Medication safety in long-term care depends on layered protections. When communication processes, technology safeguards, staff education, and continuous quality improvement work together, organizations can significantly reduce the risk of LASA medication errors and better protect vulnerable residents. Leveraging the expertise of your pharmacy partner can help identify workflow risks, strengthen safeguards, and support your community’s ongoing medication safety efforts.
For a complete list of look-alike, sound-alike drug names, review ISMP’s Confused Drug Names List.
For a list of recommended Tall Man (mixed case) letters, review FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters.
