Focus on Error Prevention: Similar Drug Names
By Ian Stewart B.Sc.Phm., R.Ph.
The similarity of drug names is a common factor in the dispensing of an incorrect drug. Poor verbal or written skills can increase the risk of errors involving drugs with similar names.
Case:
A sixty year-old patient has been taking Valsartan 40mg once daily for an extended period of time. On a recent visit to his family physician, he was given a prescription for Telmisartan 40mg once daily. The prescription was taken to his regular pharmacy for processing.
As per the prescription, 90 Telmisartan 40mg was prepared and dispensed to the patient. The patient was asked if he would like to speak to the pharmacist. He replied that he did not because he has been taking the medication for some time.
The patient therefore took the Telmisartan home in the bag provided. Two days later, the patient opened the bag to take the medication and notice that the tablets were different to the Valsartan that he had been taking. He therefore contacted the pharmacy to inquire regarding the change in medication. After confirming that the pharmacy did dispense the drug that was prescribed, a call was made to the prescriber. The doctor confirmed that he did not intend to change the patient’s drug therapy, and wanted Valsartan 40mg to be dispensed as previous.
| Hydralazine | Hydroxizine |
| Chlorpromazine | Chlorpropamide |
| Ceftin ® | Cefzil ® |
| Dicetel ® | Diclectin ® |
| Desipramine | Imipramine |
| Dimenhydrinate | Diphenhydramine |
| Fluocinonide | Fluocinolone |
| Hycomine ® | Hycodan ® |
| pantoprazole mag | pantoprazole sodium |
| Lasix ® | Losec ® |
| Nitrazadon ® | Nefazodone |
| Percodan ® | Percocet ® |
Possible Contributing Factors:
- Valsartan and Telmisartan have similar names, indications and strengths (40mg).
- The patient’s medication history was not consulted by the pharmacy assistant entering the prescription or the pharmacist checking the prescription to identify any changes in drug therapy.
- The patient did not receive counselling though the pharmacy believed that he did not take the medication previously.
Recommendations:
- Be aware of the potential for error when dispensing drugs with similar names. To the left is an abbreviated list of problematic drug pairs. A more comprehensive list can be accessed at: http://www.ismp.org/tools/confuseddrugnames.pdf. Accessed Jan. 30, 2015.
- The patient’s medication history should be consulted to identify changes in drug therapy or potential prescribing errors.
- New drug therapy should be flagged to ensure the patient receives the appropriate counselling. If the patient indicates they have the taking the medication, investigate the discrepancy.
- Advise pharmacy staff to avoid asking patients receiving new drug therapy if they would like to speak with the pharmacist. Patients in a hurry may simply say no. Hence, an opportunity to provide much needed information and to catch a potential error is missed. Instead, the patient can be informed that “the pharmacist would like to speak with you regarding your medication.”
Please continue to send reports of medication errors in confidence to Ian Stewart at: [email protected].
Please ensure that all identifying information (e.g. patient name, pharmacy name, healthcare provider name, etc.) are removed before submitting.