Look-Alike Sound-Alike Drug Errors – Protect Yourself

Medication errors are an important health risk. Human error is of course a factor, however, frequently there is a root cause or system process problem that allows that error to occur. Take for example the antihistamine drug Zyrtec (generic name cetirizine) and the antipsychotic agent Zyprexa (generic name olanzapine). Both are available as white 5 mg and 10 mg tablets and they are often stored near each other on pharmacy shelves. Add to this the possibility of physician handwriting legibility problems and you have well, a prescription for disaster.

This example is just one of many look-alike, sound-alike drug combinations that can and have resulted in the wrong medicine being dispensed to patients – and you can imagine the consequences. Eli Lilly, the maker of Zyprexa responsibly issued a “Dear Doctor” letter last year to warn healthcare professionals about the potential for confusion with Zyrtec because of reported dispensing errors.

There are two important things that you as a patient can do to protect yourself against these types of errors – 1) double check that the drug your physician prescribed for you is the drug on your vial label; and 2) that the actual tablets or capsules in the vial are correct for that drug. Here is what you need to do:

• Make sure you know the name of the drug being prescribed for you by your physician. Have the physician write it down. If your doctor submits the prescription electronically ask for a copy.

• Ask your physician to place the indication for the drug on the prescription. If there is any question by the pharmacist about the look-alike, sound-alike drug, the indication will be a further check for the pharmacist and later for you on your vial label.

• Check your vial label drug name against the one your physician said he was prescribing for you.

• Lastly, many pharmacies now include a tablet description (eg. white coated tablet) and code imprint (like “XYZ 123”) on the vial label. Look carefully at the tablets or capsules in the vial and check them for consistency with this information.

The Institute for Safe Medication Practices has put together a list of drug names that have been confused resulting in medication errors. This doesn't mean that there is always a problem when these drugs are dispensed, but you may want to check to see if you are taking any of the medications on the list.

Medication use has become a very complex process and although healthcare professionals make every effort to be careful, you should consider yourself to be the final check in the medication error prevention process. Taking these steps to protect yourself is not optional. . .you need to be an active participant in your own health care safety.