NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Safety Alert: Drugs with Similar Names

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There are several examples of errors which have happened because drugs have similar formulations or strengths. Common examples include morphine tablets versus morphine SR tablets or oxycodone capsules (standard release) versus oxycodone tablets (modified release).

 

Errors can also happen when drugs have similar names; these can be prescribing, administration or dispensing errors. Some such mix-ups are potentially life-threatening; for example if propranolol was dispensed in error when prednisolone was intended or if mercaptopurine was prescribed instead of mercaptamine.  The risk of dispensing or administration errors may be compounded by the fact that medicines with similar names are often stored near each other (due to alphabetical storage) and, in the case of generic products, may have similar packaging.

 

Examples of other medicines with similar names where errors have been reported include:

 

  • amisulpride / amiodarone
  • azathioprine / azithromycin
  • clarithromycin / ciprofloxacin / ciprofibrate / clindamycin
  • hydroxyzine / hydralazine
  • medroxyprogesterone / methylprednisolone
  • risperidone / ropinirole

 

 

Learning points:

For prescribers:

 

  • Is the drug you are prescribing appropriate for the patient and the condition being treated?
  • Ensure medicines reconciliation processes are followed consistently, eg two independent sources of information should always be used to confirm a medication history.
  • If continuing a medicine initiated by another prescriber, eg on admission to or discharge from hospital, take the opportunity to confirm the prescribed medicine is appropriate for that patient and condition.
  • Ensure what you have written on the medicines administration chart / prescription is legible and clear.

 

 

For staff administering / dispensing a medicine

 

  • Read the whole name of the medicine carefully
  • Consider whether the prescribed dose is reasonable? 
  • Is the dose easily measurable from the available strengths of the product?
  • What quantity of tablets/capsules/liquid do you need to give?  Does it seem like an unusually large quantity?
  • Check - does the patient have a clear indication for the medicine prescribed?
  • Check - is this medicine what the patient is expecting to receive?
  • Make a final check before administering that the medicine you are about to give is exactly what has been prescribed.

 

 

Good practice point for all

  • Consider storing medicines with similar names or packaging separately.