Drug names are designed to tell you a lot about the product, but they can also lead to confusion.
When drug names look-alike or sound-alike, dispensing errors, incorrect dosing, and patient harm can potentially occur.
Here are the top 10 sound-alike and look-alike drug names that can be easily confused, compiled by the department of pharmacy services at the SUNY Downstate Medical Center in Brooklyn, N.Y. (To see additions to the comprehensive list from ISMP since 2015, go here.)
Read Next: 9 Tips for Avoiding Confusion Between Drugs
1. Novolin® vs. Novolog® vs. Novolin® 70/30
NOVOLIN® (human insulin products)
NOVOLOG® (human insulin apart)
NOVOLIN® 70/30 (70 percent isophane insulin [NPH] and 30 percent insulin regular)
These insulin products have similar names, strengths and concentration ratios. These similarities can lead to medication errors and mix-ups that can result in hypoglycemia or poor diabetes control.
2. Clonidine vs. clonazepam
CATAPRES® (clonidine)
KLONOPIN® (clonazepam)
Catapres’ generic name, clonidine, can easily be confused with clonazepam, the generic name for Klonopin. If these drugs are mixed-up, patients can experience hypotension, loss of seizure control or other serious adverse problems.
3. Ambisome® vs. Abelcet® vs. Amphocin®, Fungizone®
AMBISOME® (amphotericin B liposomal)
ABELCET® (amphotericin B lipid complex)
AMPHOCIN®, FUNGIZONE® (amphotericin B desoxycholate, conventional amphotericin B)
Because doses of these lipid-based products vary and are usually higher than conventional products, they can be easily confused. Confusion between products can result in respiratory arrest, renal failure and sometimes death.
4. Metformin vs. metronidazole
GLUCOPHAGE® (metformin)
FLAGYL® (metronidazole)
Poor handwriting can lead to confusion between the name and dosage strengths of these drugs, and these mix-ups can result in hypoglycemia or untreated infection.
5. Vinblastine vs. vincristine
VELBAN® (vinblastine)
ONCOVIN® (vincristine)
Fatal errors can occur, often due to name similarity, when patients are given vincristine at a vinblastine dose.
6. Tramadol vs. trazodone vs. toradol
ULTRAM® (tramadol)
DESYREL® (trazodone)
KETOROLAC® (toradol)
These three drugs have similar generic names, and mix-ups can lead to a decline in pain control, change in psychiatric symptoms or other serious side effects.
7. Hydroxyzine vs. hydralazine vs. hydrochlorothiazide
VISTARIL®, ATARAX® (hydroxyzine)
APRESOLINE® (hydralazine)
HYDRODIURIL® (hydrochlorothiazide)
These drugs with similar names and dosage strengths can result in mix-ups that can cause sedation, hypotension or other serious adverse effects.
8. Avandia® or Cardura® vs. Coumadin®
COUMADIN® (warfarin)
AVANDIA® (rosiglitazone)
CARDURA® (doxazosin)
Avandia, which is used for type II diabetes, and Cardura, which is used for blood pressure or urinary symptoms, can be mistaken for Coumadin, an anticoagulant, and visa versa, because of bad handwriting.
9. Hydromorphone vs. morphine
DILAUDID® (hydromorphone) injection
ASTRAMORPH™, DURAMORPH®, INFUMORPH® (morphine) injection
There’s a misconception that hydromorphone is the generic equivalent of morphine, but hydromorphone is actually four to eight times more potent. If confused, this switch can be fatal.
10. Celebrex® vs. Cerebyx® vs. Celexa®
CELEBREX® (celecoxib)
CEREBYX® (fosphenytoin)
CELEXA® (citalopram)
These three drugs have similar brand names. Poor handwriting can lead to confusion. If switched, patients can experience a decline in mental status, lack of pain or seizure control or other serious side effects.
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