Medication safety is a critical component of modern healthcare. Medication errors in hospitals are a significant concern, impacting patient safety and healthcare quality. Studies indicate that approximately 10% of hospital patients experience a medication error.1 Among the many challenges that healthcare professionals face, look-alike and sound-alike (LASA) drugs represent a significant risk to patient safety.
What are look-alike and sound-alike drugs?
Look-alike and sound-alike drugs, often referred to as LASA drugs, are medications that can easily be confused due to their similar appearances, names, or packaging. Confusion of these drugs can affect prescribing, dispensing, and administration, leading to medication errors.
These medications, which may appear visually similar or have phonetically similar names, can lead to medication errors with potentially serious consequences. Understanding these risks and implementing strategies to mitigate them play a vital role in enhancing patient safety.
Tools to help prevent medication errors
Globally, medication-related errors account for 5% to 41.3% of all hospital admissions and 22% of readmissions after discharge.2 The most common types of medication errors include dosing errors, omissions, and administration of the wrong drug. Notably, 68% of medication errors occur during administration, and 24% during prescribing.3
These statistics underscore the critical need for robust clinical decision support (CDS) tools, medication safety protocols, and continuous efforts to reduce errors in healthcare settings. Numerous studies indicate that adoption of CDS tools has been shown to significantly reduce medication errors in hospital settings. Trusted CDS tools include resources like “do not confuse” drug lists and use tall man lettering to help clinicians as they build out their local facility resources to include the most appropriate LASA drugs for their country and organization.
The impact on medication safety and patient safety
Medication errors from LASA drugs can disrupt treatment plans and, in some cases, result in serious harm to the patient. For example, a mix-up between hydralazine (a medication used to lower blood pressure) and hydroxyzine (an antihistamine) could lead to unintended and potentially dangerous consequences.
This highlights the importance of collaboration between healthcare providers, pharmacists, and patients to ensure medication safety at every step. Organizations like the Food and Drug Administration (FDA) and the Institute for Safe Medication Practices (ISMP) also play an indispensable role in identifying and addressing LASA drugs to protect public health.
The role of ISMP and its recommendations
The ISMP is an industry leader in medication safety and regularly issues an updated list of LASA medicines,4 which can be used as a guide to identify LASA drug pairs. Its trusted list of confused drug names identifies LASA medicines such as metronidazole and metformin. These examples highlight the risks associated with phonetic or visual similarities.
Healthcare providers are encouraged to refer to ISMP’s resources, including the ISMP Medication Safety Alert and its detailed LASA medication list, available at www.ismp.org. These actionable tools assist clinicians in recognizing and preventing potential errors before they occur.
In order to best protect patient safety, and save time for patient care, clinicians need access to this information directly within their clinical workflow. As healthcare providers select evidence-based tools for clinician decision support, it’s important to assess whether they include these LASA medication lists, and how often they are updated.
Examples of look-alike and sound-alike drugs
Beyond the LASA list, there are specific pairs that are particularly concerning. Here are a few notable examples:
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Clonidine vs. Klonopin – Misidentifying these drugs could result in prescribing errors for hypertension versus anxiety.
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Celebrex vs. Celexa – Confusions may arise between a pain reliever and an antidepressant.
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Hydromorphone vs. morphine – Both are high-potency opioids but with different dosages and effects.
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Toradol vs tramadol - Both are used for pain, but one has anti-inflammatory properties and the other is controlled substance
By closely monitoring these pairings, healthcare professionals can significantly reduce medication-related risks.
Characteristics of look-alike and sound-alike drugs
What makes drugs look alike?
Drugs with similar packaging and formulations can easily cause visual confusion. For instance, manufacturers often use similar colors, fonts, or bottle shapes for medications in the same therapeutic class. While this may simplify manufacturing, it increases the likelihood of mix-ups for healthcare professionals and pharmacists working in high-pressure environments.
An example of such a confusion involves epinephrine and ephedrine, which have similar packaging but very different clinical uses. These seemingly minor design choices can have profound implications for patient safety.
Phonetic challenges in sound-alike drugs
Sound-alike issues arise due to phonetic similarities in drug names. For example, drugs like Celexa and Zyprexa sound remarkably similar when spoken, especially in fast-paced environments. These challenges underscore the importance of careful communication between providers, pharmacists, and patients.
The role of familiarity in medication safety
Without proper awareness of generic and brand names, healthcare professionals may accidentally prescribe the wrong medication. A lack of familiarity with frequently confused medications, such as doxorubicin and daunorubicin, can lead to catastrophic errors during treatment, especially in sensitive areas like oncology.
The World Health Organization emphasizes that education and training must remain at the heart of medication error prevention. Institutions can improve patient safety by ensuring providers stay up to date on common LASA drug pairs.
Real-world consequences of LASA drug mix-ups
The impact of LASA drug errors can be life-altering. Consider the potential harm if an antidepressant medication like sertraline is accidentally swapped with an antihistamine like cetirizine. Such errors highlight the necessity of vigilance within every point of care.
Strategies to mitigate medication errors
Fortunately, there are proactive strategies to minimize the risk of LASA medication errors and safeguard patients:
Tall man letters and labeling strategies
One of the most effective tools in combating LASA confusion is the use of tall man letters—a proven technique where uppercase letters are strategically applied to differentiate look-alike names. For example:
- hydrOXYzine vs. hydrALAZINE
- cloNIDine vs. KlonoPIN
These distinctions draw attention to differences in drug names, helping healthcare providers avoid costly mistakes. The FDA and ISMP recommend the widespread implementation of such recommended tall man strategies as a standard practice.
Packaging design and regulatory approaches
To reduce errors, barriers such as similar packaging and ambiguous naming can be redesigned with patient safety in mind. The FDA actively works with pharmaceutical companies to address these issues during the drug approval process, incentivizing safer designs.
Additional preventative techniques
Healthcare organizations can deploy the following measures to enhance medication safety:
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Running focused training for staff on LASA drugs commonly used at their specific site of practice.
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Encouraging open communication between providers, pharmacists, other healthcare professionals, and patients.
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Implementing barcode medication administration (BCMA) systems.
Ensuring patient safety through collaboration
Patient safety is not a one-person mission; rather, it requires collaboration from the entire healthcare team, including providers, pharmacists, and support staff, as well as pharmaceutical companies, and vendors that curate the content of clinical decision support solutions.
The role of healthcare professionals in minimizing risk
Healthcare professionals, including pharmacists, nurses, physicians and many others, are at the forefront of detecting LASA risks. By conscientiously reviewing medication orders and explaining potential risks to patients, they can prevent many errors before they occur. For example, clearly explaining the differences between medications like Lanoxin and levothyroxine can make all the difference in patient outcomes.
Encouraging proactive patient education
Patients should feel empowered to ask questions about their medications. To support them, healthcare providers can educate patients using trusted resources, such as the ISMP's list of LASA drugs or government websites ending in .gov for verified information. This proactive approach ensures patients stay informed and alert.
The role of clinical decision support (CDS) systems
CDS systems can play a critical role in reducing LASA medication errors— especially when integrated into electronic health records (EHR) to provide real-time alerts and guidance to healthcare providers. Here are some of the ways they can help:
- Improved drug selection: When a provider prescribes a medication, the CDS system flags LASA drugs and highlights potential name pairs, urging the provider to verify their selection.
- Enhanced order entry: Through alert mechanisms, the system prompts clinicians to double-check drug names, especially in high-risk categories like LASA medication lists.
- Streamlined communication: CDS tools often encourage the inclusion of drug indications in orders, reducing ambiguity and ensuring the right drug aligns with the intended therapy.
- Adoption of tall man letters: The best CDS systems incorporate tall man letters, a practice recommended by the ISMP and the FDA. For example, "hydrOXYzine" and "hydrALAZINE" are displayed with distinctive uppercase letters to minimize confusion between look-alike drug names.
By integrating these features, clinical decision support systems serve as an additional safety net for look-alike and sound-alike drugs, protecting both providers and patients from errors that could compromise outcomes.
Conclusion
The risks posed by look-alike and sound-alike drugs are real, but they are manageable with concerted effort, education, and the right tools. By leveraging strategies like tall man letters, referring to trusted industry resources like the ISMP list and evidence-based CDS tools, and fostering open communication across teams, the risk of LASA medication errors can be significantly reduced.
