ISMP's List of Confused Drug Names
ISMP's List of Confused Drug Names
ISMP's List of Confused Drug Names
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Institute for Safe Medication Practices<br />
ISMP’s <strong>List</strong> <strong>of</strong> <strong>Confused</strong> <strong>Drug</strong> <strong>Names</strong><br />
T<br />
his list <strong>of</strong> confused drug names, which includes look-alike and<br />
sound-alike name pairs, consists <strong>of</strong> those name pairs that have<br />
been involved in medication errors published in the ISMP<br />
Medication Safety Alert! ® and the ISMP Medication Safety Alert! ®<br />
Community/Ambulatory Care Edition. The errors involving these<br />
medications were reported to ISMP through the ISMP Medication<br />
Errors Reporting Program (MERP).<br />
This list also contains the names that appear on The Joint<br />
Commission’s (TJC) list <strong>of</strong> look-alike and sound-alike names. TJC<br />
established a National Patient Safety Goal that requires each<br />
accredited organization to identify a list <strong>of</strong> look-alike or sound-alike<br />
drugs used in the organization. Those names that appear on TJC’s list<br />
have been noted with an asterisk (*) below.<br />
©ISMP 2009<br />
<strong>Drug</strong> Name<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
Abelcet* amphotericin B*<br />
Accupril<br />
Aciphex<br />
acetaZOLAMIDE*<br />
acetoHEXAMIDE*<br />
acetic acid for irrigation<br />
glacial acetic acid<br />
acetoHEXAMIDE*<br />
acetaZOLAMIDE*<br />
Aciphex<br />
Accupril<br />
Aciphex<br />
Aricept<br />
Activase<br />
Cathflo Activase<br />
Activase<br />
TNKase<br />
Actonel<br />
Actos<br />
Actos<br />
Actonel<br />
Adacel (Tdap)<br />
Daptacel (DTaP)<br />
Adderall<br />
Inderal<br />
Advair*<br />
Advicor*<br />
Advicor*<br />
Advair*<br />
Advicor<br />
Altocor<br />
Afrin (oxymetazoline)<br />
Afrin (saline)<br />
Afrin (saline)<br />
Afrin (oxymetazoline)<br />
Aggrastat<br />
argatroban<br />
Aldara<br />
Alora<br />
Alkeran<br />
Leukeran<br />
Alkeran<br />
Myleran<br />
Allegra<br />
Viagra<br />
Alora<br />
Aldara<br />
ALPRAZolam*<br />
LORazepam*<br />
Altocor<br />
Advicor<br />
Amaryl<br />
Reminyl<br />
Ambisome* amphotericin B*<br />
Amicar*<br />
Omacor*<br />
Amikin<br />
Kineret<br />
aMILoride<br />
amLODIPine<br />
amLODIPine<br />
aMILoride<br />
amphotericin B*<br />
Abelcet*<br />
amphotericin B*<br />
Ambisome*<br />
Anacin<br />
Anacin-3<br />
<strong>Drug</strong> Name<br />
Anacin-3<br />
antacid<br />
Antivert<br />
Anzemet<br />
Apresoline<br />
argatroban<br />
argatroban<br />
Aricept<br />
Aricept<br />
aripiprazole<br />
aripiprazole<br />
Asacol<br />
Atacand<br />
Atrovent<br />
Avandamet<br />
Avandia<br />
Avandia*<br />
AVINza<br />
AVINza*<br />
Axert<br />
azaCITIDine<br />
azaTHIOprine<br />
Azilect<br />
B & O (belladonna and opium)<br />
BabyBIG<br />
Bayhep-B<br />
Bayhep-B<br />
Bayrab<br />
Bayrab<br />
Bayrho-D<br />
Bayrho-D<br />
Beano<br />
Benadryl<br />
benazepril<br />
Benicar<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
Anacin<br />
Atacand<br />
Axert<br />
Avandamet<br />
Priscoline<br />
Aggrastat<br />
Orgaran<br />
Aciphex<br />
Azilect<br />
proton pump inhibitors<br />
rabeprazole<br />
Os-Cal<br />
antacid<br />
Natru-Vent<br />
Anzemet<br />
Prandin<br />
Coumadin*<br />
INVanz<br />
Evista*<br />
Antivert<br />
azaTHIOprine<br />
azaCITIDine<br />
Aricept<br />
Beano<br />
HBIG (hepatitis B immune globulin)<br />
Bayrab<br />
Bayrho-D<br />
Bayhep-B<br />
Bayrho-D<br />
Bayhep-B<br />
Bayrab<br />
B & O (belladonna and opium)<br />
benazepril<br />
Benadryl<br />
Mevacor<br />
* These drug names are included on TJC’s list <strong>of</strong> look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements <strong>of</strong> the National Patient<br />
Safety Goals. Visit www.jointcommission.org for more information about this TJC requirement.<br />
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other<br />
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication<br />
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at<br />
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),<br />
providing legal protection and confidentiality for patient safety data and error reports it receives.<br />
Institute for Safe<br />
Medication Practices<br />
www.ismp.org<br />
1
Institute for Safe Medication Practices<br />
©ISMP 2009<br />
<strong>Drug</strong> Name<br />
ISMP’s <strong>List</strong> <strong>of</strong> <strong>Confused</strong> <strong>Drug</strong> <strong>Names</strong><br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
Betadine (with providone-iodine) Betadine (without providone-iodine)<br />
Betadine (without providone-iodine) Betadine (with providone-iodine)<br />
Bextra<br />
Zetia<br />
Bicillin C-R<br />
Bicillin L-A<br />
Bicillin L-A<br />
Bicillin C-R<br />
Bicitra<br />
Polycitra<br />
Brethine<br />
Methergine<br />
Brevibloc<br />
Brevital<br />
Brevital<br />
Brevibloc<br />
buPROPion<br />
busPIRone<br />
busPIRone<br />
buPROPion<br />
Carac<br />
Kuric<br />
carBAMazepine<br />
OXcarbazepine<br />
CARBOplatin<br />
CISplatin<br />
Cardura*<br />
Coumadin*<br />
Cathflo Activase<br />
Activase<br />
Cedax<br />
Cidex<br />
ceFAZolin<br />
cefTRIAXone<br />
cefTRIAXone<br />
ceFAZolin<br />
CeleBREX*<br />
CeleXA*<br />
CeleBREX*<br />
Cerebyx*<br />
CeleXA<br />
ZyPREXA<br />
CeleXA*<br />
CeleBREX*<br />
CeleXA*<br />
Cerebyx*<br />
Cerebyx*<br />
CeleBREX*<br />
Cerebyx*<br />
CeleXA*<br />
chlordiazePOXIDE<br />
chlorproMAZINE<br />
chlorproMAZINE<br />
chlordiazePOXIDE<br />
chlorproMAZINE<br />
chlorproPAMIDE<br />
chlorproPAMIDE<br />
chlorproMAZINE<br />
Cidex<br />
Cedax<br />
CISplatin<br />
CARBOplatin<br />
Claritin-D Claritin-D 24<br />
Claritin-D 24<br />
Claritin-D<br />
Clindesse<br />
Clindets<br />
Clindets<br />
Clindesse<br />
clomiPHENE<br />
clomiPRAMINE<br />
clomiPRAMINE<br />
clomiPHENE<br />
clonazePAM<br />
cloNIDine<br />
clonazePAM<br />
LORazepam<br />
cloNIDine<br />
clonazePAM<br />
cloNIDine*<br />
KlonoPIN*<br />
Clozaril<br />
Colazal<br />
Coagulation factor IX (recombinant) Factor IX Complex, Vapor Heated<br />
codeine<br />
Lodine<br />
Colace<br />
Cozaar<br />
<strong>Drug</strong> Name<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
Colazal<br />
Clozaril<br />
colchicine<br />
Cortrosyn<br />
Comvax<br />
Recombivax HB<br />
Cortrosyn<br />
colchicine<br />
Coumadin*<br />
Avandia*<br />
Coumadin*<br />
Cardura*<br />
Cozaar<br />
Colace<br />
Cozaar<br />
Zocor<br />
cycloSERINE<br />
cycloSPORINE<br />
cycloSPORINE<br />
cycloSERINE<br />
Cymbalta<br />
Symbyax<br />
DACTINomycin<br />
DAPTOmycin<br />
Daptacel (DTaP)<br />
Adacel (Tdap)<br />
DAPTOmycin<br />
DACTINomycin<br />
Darvocet*<br />
Percocet*<br />
Darvon<br />
Diovan<br />
DAUNOrubicin*<br />
DAUNOrubicin citrate liposomal*<br />
DAUNOrubicin*<br />
DOXOrubicin*<br />
DAUNOrubicin*<br />
IDArubicin*<br />
DAUNOrubicin citrate liposomal*<br />
DAUNOrubicin*<br />
Denavir<br />
indinavir<br />
Depakote<br />
Depakote ER<br />
Depakote ER<br />
Depakote<br />
Depo-Medrol<br />
Solu-MEDROL<br />
Depo-Provera Depo-subQ provera 104<br />
Depo-subQ provera 104<br />
Depo-Provera<br />
dexmethylphenidate<br />
methadone<br />
Diabinese<br />
Diamox<br />
Diabeta*<br />
Zebeta*<br />
Diamox<br />
Diabinese<br />
Diflucan*<br />
Diprivan*<br />
Dilacor XR<br />
Pilocar<br />
Dilaudid<br />
Dilaudid-5<br />
Dilaudid-5<br />
Dilaudid<br />
dimenhyDRINATE<br />
diphenhydrAMINE<br />
diphenhydrAMINE<br />
dimenhyDRINATE<br />
Dioval<br />
Diovan<br />
Diovan<br />
Dioval<br />
Diovan<br />
Zyban<br />
Diovan<br />
Darvon<br />
Diprivan*<br />
Diflucan*<br />
Diprivan<br />
Ditropan<br />
Ditropan<br />
Diprivan<br />
DOBUTamine<br />
DOPamine<br />
DOPamine<br />
DOBUTamine<br />
Doxil<br />
Paxil<br />
* These drug names are included on TJC’s list <strong>of</strong> look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements <strong>of</strong> the National Patient<br />
Safety Goals. Visit www.jointcommission.org for more information about this TJC requirement.<br />
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other<br />
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication<br />
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at<br />
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),<br />
providing legal protection and confidentiality for patient safety data and error reports it receives.<br />
Institute for Safe<br />
Medication Practices<br />
www.ismp.org<br />
2
Institute for Safe Medication Practices<br />
©ISMP 2009<br />
<strong>Drug</strong> Name<br />
DOXOrubicin*<br />
DOXOrubicin*<br />
DOXOrubicin*<br />
DOXOrubicin liposomal*<br />
Dulcolax (bisacodyl)<br />
Dulcolax (docusate sodium)<br />
DULoxetine<br />
Duricef<br />
Dynacin<br />
Dynacirc<br />
edetate calcium disodium<br />
edetate disodium<br />
Effexor*<br />
Effexor XR*<br />
Enbrel<br />
Engerix-B adult<br />
Engerix-B pediatric/adolescent<br />
Enjuvia<br />
ePHEDrine*<br />
EPINEPHrine*<br />
Estratest<br />
Estratest HS<br />
ethambutol<br />
Ethmozine<br />
Evista*<br />
Factor IX Complex, Vapor Heated<br />
Femara<br />
Femhrt<br />
fentaNYL<br />
Fioricet<br />
Fiorinal<br />
flavoxate<br />
Flonase<br />
Flovent<br />
flumazenil<br />
FLUoxetine<br />
FLUoxetine<br />
fluvoxamine<br />
Folex<br />
folic acid*<br />
folinic acid (leucovorin calcium)*<br />
Foltx<br />
fomepizole<br />
Foradil<br />
gentamicin<br />
gentian violet<br />
ISMP’s <strong>List</strong> <strong>of</strong> <strong>Confused</strong> <strong>Drug</strong> <strong>Names</strong><br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
DAUNOrubicin*<br />
DOXOrubicin liposomal*<br />
IDArubicin*<br />
DOXOrubicin*<br />
Dulcolax (docusate sodium)<br />
Dulcolax (bisacodyl)<br />
FLUoxetine<br />
Ultracet<br />
Dynacirc<br />
Dynacin<br />
edetate disodium<br />
edetate calcium disodium<br />
Effexor XR*<br />
Effexor*<br />
Levbid<br />
Engerix-B pediatric/adolescent<br />
Engerix-B adult<br />
Januvia<br />
EPINEPHrine*<br />
ePHEDrine*<br />
Estratest HS<br />
Estratest<br />
Ethmozine<br />
ethambutol<br />
AVINza*<br />
Coagulation factor IX (recombinant)<br />
Femhrt<br />
Femara<br />
SUFentanil<br />
Fiorinal<br />
Fioricet<br />
fluvoxamine<br />
Flovent<br />
Flonase<br />
influenza virus vaccine<br />
PARoxetine<br />
DULoxetine<br />
flavoxate<br />
Foltx<br />
folinic acid (leucovorin calcium)*<br />
folic acid*<br />
Folex<br />
omeprazole<br />
Toradol<br />
gentian violet<br />
gentamicin<br />
<strong>Drug</strong> Name<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
glacial acetic acid<br />
acetic acid for irrigation<br />
glipiZIDE<br />
glyBURIDE<br />
glyBURIDE<br />
glipiZIDE<br />
Granulex<br />
Regranex<br />
guaiFENesin<br />
guanFACINE<br />
guanFACINE<br />
guaiFENesin<br />
HBIG (hepatitis B immune globulin)<br />
BabyBIG<br />
Healon<br />
Hyalgan<br />
heparin*<br />
Hespan*<br />
Hespan*<br />
heparin*<br />
HMG-CoA Reductase Inhibitors ("statins")<br />
nystatin<br />
HumaLOG*<br />
HumuLIN*<br />
HumaLOG*<br />
NovoLOG*<br />
HumaLOG Mix 75/25 HumuLIN 70/30<br />
Humapen Memoir (for use with HumaLOG)<br />
Humira Pen<br />
Humira Pen<br />
Humapen Memoir (for use with HumaLOG)<br />
HumuLIN*<br />
NovoLIN*<br />
HumuLIN*<br />
HumaLOG*<br />
HumuLIN 70/30 HumaLOG Mix 75/25<br />
Hyalgan<br />
Healon<br />
hydrALAZINE*<br />
hydrOXYzine*<br />
HYDROcodone*<br />
oxyCODONE*<br />
hydrOXYzine<br />
Hydrogesic<br />
hydrOXYzine*<br />
hydrALAZINE*<br />
IDArubicin*<br />
DAUNOrubicin*<br />
IDArubicin*<br />
DOXOrubicin*<br />
Inderal<br />
Adderall<br />
indinavir<br />
Denavir<br />
inFLIXimab<br />
riTUXimab<br />
influenza virus vaccine<br />
flumazenil<br />
influenza virus vaccine tuberculin purified protein derivative (PPD)<br />
Inspra<br />
Spiriva<br />
INVanz<br />
AVINza<br />
iodine<br />
Lodine<br />
Isordil<br />
Plendil<br />
isotretinoin<br />
tretinoin<br />
Jantoven<br />
Janumet<br />
Jantoven<br />
Januvia<br />
Janumet<br />
Jantoven<br />
Janumet<br />
Januvia<br />
Januvia<br />
Enjuvia<br />
Januvia<br />
Jantoven<br />
Januvia<br />
Janumet<br />
Kaopectate (bismuth subsalcylate) Kaopectate (docusate calcium)<br />
Kaopectate (docusate calcium) Kaopectate (bismuth subsalcylate)<br />
K-Phos Neutral<br />
Neutra-Phos-K<br />
* These drug names are included on TJC’s list <strong>of</strong> look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements <strong>of</strong> the National Patient<br />
Safety Goals. Visit www.jointcommission.org for more information about this TJC requirement.<br />
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other<br />
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication<br />
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at<br />
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),<br />
providing legal protection and confidentiality for patient safety data and error reports it receives.<br />
Institute for Safe<br />
Medication Practices<br />
www.ismp.org<br />
3
Institute for Safe Medication Practices<br />
©ISMP 2009<br />
ISMP’s <strong>List</strong> <strong>of</strong> <strong>Confused</strong> <strong>Drug</strong> <strong>Names</strong><br />
<strong>Drug</strong> Name<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
<strong>Drug</strong> Name<br />
Kaletra<br />
Keppra<br />
Lupron Depot-Ped<br />
Keflex<br />
Keppra<br />
Luvox<br />
Keppra<br />
Kaletra<br />
Lyrica<br />
Keppra<br />
Keflex<br />
Maalox<br />
Ketalar<br />
ketorolac<br />
Maalox Total Stomach Relief<br />
ketorolac<br />
Ketalar<br />
Matulane<br />
Kineret<br />
Amikin<br />
Materna<br />
KlonoPIN* cloNIDine *<br />
Maxzide<br />
Kuric<br />
Carac<br />
Menactra<br />
Kwell<br />
Qwell<br />
Menomune<br />
LaMICtal<br />
LamISIL<br />
Mephyton<br />
LamISIL<br />
LaMICtal<br />
Metadate<br />
lamiVUDine*<br />
lamoTRIgine*<br />
Metadate CD<br />
lamoTRIgine*<br />
lamiVUDine*<br />
Metadate ER<br />
lamoTRIgine<br />
levothyroxine<br />
Metadate ER<br />
Lanoxin<br />
levothyroxine<br />
metFORMIN*<br />
lanthanum carbonate<br />
lithium carbonate<br />
methadone<br />
Lantus<br />
Lente<br />
methadone<br />
Lasix<br />
Luvox<br />
methadone<br />
Lente<br />
Lantus<br />
methadone<br />
leucovorin calcium*<br />
Leukeran*<br />
methadone<br />
Leukeran<br />
Alkeran<br />
Methergine<br />
Leukeran<br />
Myleran<br />
methimazole<br />
Leukeran*<br />
leucovorin calcium*<br />
methylphenidate<br />
Levbid<br />
Enbrel<br />
metolazone<br />
levetiracetam<br />
lev<strong>of</strong>loxacin<br />
metoprolol succinate<br />
lev<strong>of</strong>loxacin<br />
levetiracetam<br />
metoprolol tartrate<br />
levothyroxine<br />
lamoTRIgine<br />
metroNIDAZOLE*<br />
levothyroxine<br />
Lanoxin<br />
Mevacor<br />
Lexapro<br />
Loxitane<br />
Micronase<br />
Lipitor<br />
Loniten<br />
Microzide<br />
Lipitor<br />
ZyrTEC<br />
Microzide<br />
lithium carbonate<br />
lanthanum carbonate<br />
midodrine<br />
Lodine<br />
codeine<br />
Midrin<br />
Lodine<br />
iodine<br />
mifepristone<br />
Loniten<br />
Lipitor<br />
Miralax<br />
Lopressor<br />
Lyrica<br />
Mirapex<br />
LORazepam*<br />
ALPRAZolam*<br />
misoprostol<br />
LORazepam<br />
clonazePAM<br />
morphine*<br />
LORazepam<br />
Lovaza<br />
morphine - non-concentrated oral liquid*<br />
Lotronex<br />
Protonix<br />
morphine - oral liquid concentrate*<br />
Lovaza<br />
LORazepam<br />
Motrin<br />
Loxitane<br />
Lexapro<br />
MS Contin*<br />
Loxitane<br />
Soriatane<br />
Mucinex*<br />
Lunesta<br />
Neulasta<br />
Mucomyst*<br />
Lupron Depot-3 Month<br />
Lupron Depot-Ped<br />
Myleran<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
Lupron Depot-3 Month<br />
Lasix<br />
Lopressor<br />
Maalox Total Stomach Relief<br />
Maalox<br />
Materna<br />
Matulane<br />
Microzide<br />
Menomune<br />
Menactra<br />
methadone<br />
methadone<br />
Metadate ER<br />
Metadate CD<br />
methadone<br />
metroNIDAZOLE*<br />
dexmethylphenidate<br />
Mephyton<br />
Metadate ER<br />
Metadate<br />
methylphenidate<br />
Brethine<br />
metolazone<br />
methadone<br />
methimazole<br />
metoprolol tartrate<br />
metoprolol succinate<br />
metFORMIN*<br />
Benicar<br />
Microzide<br />
Maxzide<br />
Micronase<br />
Midrin<br />
midodrine<br />
misoprostol<br />
Mirapex<br />
Miralax<br />
mifepristone<br />
HYDROmorphone*<br />
morphine - oral liquid concentrate*<br />
morphine - non-concentrated oral liquid*<br />
Neurontin<br />
OxyCONTIN*<br />
Mucomyst*<br />
Mucinex*<br />
Alkeran<br />
* These drug names are included on TJC’s list <strong>of</strong> look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements <strong>of</strong> the National Patient<br />
Safety Goals. Visit www.jointcommission.org for more information about this TJC requirement.<br />
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other<br />
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication<br />
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at<br />
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),<br />
providing legal protection and confidentiality for patient safety data and error reports it receives.<br />
Institute for Safe<br />
Medication Practices<br />
www.ismp.org<br />
4
Institute for Safe Medication Practices<br />
©ISMP 2009<br />
ISMP’s <strong>List</strong> <strong>of</strong> <strong>Confused</strong> <strong>Drug</strong> <strong>Names</strong><br />
<strong>Drug</strong> Name<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
<strong>Drug</strong> Name<br />
Myleran<br />
Leukeran<br />
OXcarbazepine<br />
Narcan<br />
Norcuron<br />
oxyCODONE*<br />
Natru-Vent<br />
Atrovent<br />
oxyCODONE*<br />
Navane<br />
Norvasc<br />
OxyCONTIN*<br />
Neo-Synephrine (oxymetazoline) Neo-Synephrine (phenylephrine)<br />
OxyCONTIN*<br />
Neo-Synephrine (phenylephrine) Neo-Synephrine (oxymetazoline)<br />
paclitaxel<br />
Neulasta<br />
Lunesta<br />
paclitaxel protein-bound particles<br />
Neulasta<br />
Neumega<br />
Pamelor<br />
Neumega<br />
Neupogen<br />
Pamelor<br />
Neumega<br />
Neulasta<br />
Panlor DC<br />
Neupogen<br />
Neumega<br />
paregoric (camphorated tincture <strong>of</strong> opium)*<br />
Neurontin<br />
Motrin<br />
PARoxetine<br />
Neurontin<br />
Noroxin<br />
Patanol<br />
Neutra-Phos-K<br />
K-Phos Neutral<br />
Pavulon<br />
NexAVAR<br />
NexIUM<br />
Paxil<br />
NexIUM<br />
NexAVAR<br />
Paxil<br />
niCARdipine<br />
NIFEdipine<br />
Paxil<br />
NIFEdipine<br />
niCARdipine<br />
Peptavlon<br />
NIFEdipine<br />
niMODipine<br />
Percocet*<br />
niMODipine<br />
NIFEdipine<br />
Percocet<br />
Norcuron<br />
Narcan<br />
PENTobarbital<br />
Normodyne<br />
Norpramin<br />
PHENobarbital<br />
Noroxin<br />
Neurontin<br />
Pilocar<br />
Norpramin<br />
Normodyne<br />
Platinol<br />
Norvasc<br />
Navane<br />
Plavix<br />
NovoLIN*<br />
HumuLIN*<br />
Plendil<br />
NovoLIN*<br />
NovoLOG*<br />
pneumococcal 7-valent vaccine<br />
NovoLIN 70/30* NovoLOG Mix 70/30*<br />
pneumococcal polyvalent vaccine<br />
NovoLOG*<br />
HumaLOG*<br />
Polycitra<br />
NovoLOG*<br />
NovoLIN*<br />
Prandin<br />
NovoLOG Flexpen<br />
NovoLOG Mix 70/30 Flexpen<br />
Precare<br />
NovoLOG Mix 70/30 Flexpen<br />
NovoLOG Flexpen<br />
Precose<br />
NovoLOG Mix 70/30* NovoLIN 70/30*<br />
prednisoLONE<br />
nystatin<br />
HMG-CoA Reductase Inhibitors ("statins")<br />
predniSONE<br />
Occlusal-HP<br />
Ocuflox<br />
PriLOSEC*<br />
Ocuflox<br />
Occlusal-HP<br />
Priscoline<br />
OLANZapine<br />
QUEtiapine<br />
probenecid<br />
Omacor*<br />
Amicar*<br />
Procan SR<br />
omeprazole<br />
fomepizole<br />
Procanbid<br />
opium tincture*<br />
paregoric (camphorated tincture <strong>of</strong> opium)*<br />
Procanbid<br />
Oracea<br />
Orencia<br />
Procardia XL<br />
Orencia<br />
Oracea<br />
Procet<br />
Orgaran<br />
argatroban<br />
Prograf<br />
Ortho Tri-Cyclen<br />
Ortho Tri-Cyclen LO<br />
propylthiouracil<br />
Ortho Tri-Cyclen LO<br />
Ortho Tri-Cyclen<br />
Protain XL<br />
Os-Cal<br />
Asacol<br />
protamine<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
carBAMazepine<br />
HYDROcodone*<br />
OxyCONTIN*<br />
MS Contin*<br />
oxyCODONE*<br />
paclitaxel protein-bound particles<br />
paclitaxel<br />
Panlor DC<br />
Tambocor<br />
Pamelor<br />
opium tincture*<br />
FLUoxetine<br />
Platinol<br />
Peptavlon<br />
Doxil<br />
Taxol<br />
Plavix<br />
Pavulon<br />
Darvocet*<br />
Procet<br />
PHENobarbital<br />
PENTobarbital<br />
Dilacor XR<br />
Patanol<br />
Paxil<br />
Isordil<br />
pneumococcal polyvalent vaccine<br />
pneumococcal 7-valent vaccine<br />
Bicitra<br />
Avandia<br />
Precose<br />
Precare<br />
predniSONE<br />
prednisoLONE<br />
PROzac*<br />
Apresoline<br />
Procanbid<br />
Procanbid<br />
probenecid<br />
Procan SR<br />
Protain XL<br />
Percocet<br />
PROzac<br />
Purinethol<br />
Procardia XL<br />
Protonix<br />
* These drug names are included on TJC’s list <strong>of</strong> look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements <strong>of</strong> the National Patient<br />
Safety Goals. Visit www.jointcommission.org for more information about this TJC requirement.<br />
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other<br />
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication<br />
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at<br />
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),<br />
providing legal protection and confidentiality for patient safety data and error reports it receives.<br />
Institute for Safe<br />
Medication Practices<br />
www.ismp.org<br />
5
Institute for Safe Medication Practices<br />
ISMP’s <strong>List</strong> <strong>of</strong> <strong>Confused</strong> <strong>Drug</strong> <strong>Names</strong><br />
©ISMP 2009<br />
<strong>Drug</strong> Name<br />
proton pump inhibitors<br />
Protonix<br />
Protonix<br />
PROzac<br />
PROzac*<br />
Purinethol<br />
QUEtiapine<br />
quiNIDine<br />
quiNINE<br />
Qwell<br />
rabeprazole<br />
Razadyne<br />
Recombivax HB<br />
Regranex<br />
Reminyl<br />
Reminyl<br />
Reprexain<br />
Restoril<br />
Retrovir*<br />
Rifadin<br />
Rifamate<br />
rifampin<br />
rifampin<br />
Rifater<br />
rifaximin<br />
Risperdal<br />
risperidone<br />
Ritalin<br />
Ritalin LA<br />
Ritalin SR<br />
ritodrine<br />
ritonavir*<br />
riTUXimab<br />
Robinul<br />
ropinirole<br />
Roxanol<br />
Roxanol<br />
Roxicet<br />
Roxicodone Intensol<br />
Rozerem<br />
Salagen<br />
SandIMMUNE<br />
SandoSTATIN<br />
saquinavir<br />
saquinavir (free base)<br />
saquinavir mesylate<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
aripiprazole<br />
Lotronex<br />
protamine<br />
Prograf<br />
PriLOSEC*<br />
propylthiouracil<br />
OLANZapine<br />
quiNINE<br />
quiNIDine<br />
Kwell<br />
aripiprazole<br />
Rozerem<br />
Comvax<br />
Granulex<br />
Robinul<br />
Amaryl<br />
ZyPREXA<br />
Risperdal<br />
ritonavir*<br />
Rifater<br />
rifampin<br />
Rifamate<br />
rifaximin<br />
Rifadin<br />
rifampin<br />
Restoril<br />
ropinirole<br />
ritodrine<br />
Ritalin SR<br />
Ritalin LA<br />
Ritalin<br />
Retrovir*<br />
inFLIXimab<br />
Reminyl<br />
risperidone<br />
Roxicodone Intensol<br />
Roxicet<br />
Roxanol<br />
Roxanol<br />
Razadyne<br />
selegiline<br />
SandoSTATIN<br />
SandIMMUNE<br />
SINEquan<br />
saquinavir mesylate<br />
saquinavir (free base)<br />
<strong>Drug</strong> Name<br />
Sarafem<br />
selegiline<br />
Serophene<br />
SEROquel<br />
SEROquel<br />
sertraline<br />
Serzone<br />
SINEquan<br />
SINEquan<br />
SINEquan<br />
SINEquan<br />
Singulair<br />
sitaGLIPtin<br />
Solu-CORTEF<br />
Solu-MEDROL<br />
Solu-MEDROL<br />
Sonata<br />
Soriatane<br />
Soriatane<br />
Soriatane<br />
sotalol<br />
Spiriva<br />
Sudafed<br />
Sudafed<br />
Sudafed PE<br />
SUFentanil<br />
sulfADIAZINE<br />
sulfiSOXAZOLE<br />
SUMAtriptan<br />
SUMAtriptan<br />
Symbyax<br />
Tambocor<br />
Taxol<br />
Taxol<br />
Taxotere<br />
TEGretol<br />
TEGretol<br />
TEGretol<br />
TEGretol XR<br />
Tequin<br />
Tequin<br />
Testoderm TTS<br />
Testoderm TTS<br />
Testoderm with Adhesive<br />
Testoderm with Adhesive<br />
Testoderm<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
Serophene<br />
Salagen<br />
Sarafem<br />
Serzone<br />
SINEquan<br />
Soriatane<br />
SEROquel<br />
saquinavir<br />
SEROquel<br />
Singulair<br />
Zonegran<br />
SINEquan<br />
SUMAtriptan<br />
Solu-MEDROL<br />
Depo-Medrol<br />
Solu-CORTEF<br />
Soriatane<br />
Loxitane<br />
sertraline<br />
Sonata<br />
Sudafed<br />
Inspra<br />
sotalol<br />
Sudafed PE<br />
Sudafed<br />
fentaNYL<br />
sulfiSOXAZOLE<br />
sulfADIAZINE<br />
sitaGLIPtin<br />
zolmitriptan<br />
Cymbalta<br />
Pamelor<br />
Taxotere<br />
Paxil<br />
Taxol<br />
TEGretol XR<br />
Tequin<br />
TRENtal<br />
TEGretol<br />
TEGretol<br />
Ticlid<br />
Testoderm<br />
Testoderm with Adhesive<br />
Testoderm<br />
Testoderm TTS<br />
Testoderm TTS<br />
* These drug names are included on TJC’s list <strong>of</strong> look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements <strong>of</strong> the National Patient<br />
Safety Goals. Visit www.jointcommission.org for more information about this TJC requirement..<br />
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other<br />
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication<br />
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at<br />
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),<br />
providing legal protection and confidentiality for patient safety data and error reports it receives.<br />
Institute for Safe<br />
Medication Practices<br />
www.ismp.org<br />
6
Institute for Safe Medication Practices<br />
©ISMP 2009<br />
ISMP’s <strong>List</strong> <strong>of</strong> <strong>Confused</strong> <strong>Drug</strong> <strong>Names</strong><br />
<strong>Drug</strong> Name<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
<strong>Drug</strong> Name<br />
Testoderm<br />
Testoderm with Adhesive<br />
VZIG (varicella-zoster immuneglobulin)<br />
tetanus diptheria toxoid (Td) tuberculin purified protein derivative (PPD)<br />
Wellbutrin SR*<br />
Thalomid<br />
Thiamine<br />
Wellbutrin XL*<br />
Thiamine<br />
Thalomid<br />
Xanax*<br />
tiaGABine*<br />
tiZANidine*<br />
Xeloda<br />
Tiazac<br />
Ziac<br />
Xenical<br />
Ticlid<br />
Tequin<br />
Yasmin<br />
tiZANidine*<br />
tiaGABine*<br />
Yaz<br />
TNKase<br />
Activase<br />
Zantac*<br />
TNKase<br />
t-PA<br />
Zantac*<br />
Tobradex<br />
Tobrex<br />
Zebeta*<br />
Tobrex<br />
Tobradex<br />
Zebeta<br />
TOLAZamide<br />
TOLBUTamide<br />
Zegerid<br />
TOLBUTamide<br />
TOLAZamide<br />
Zelapar (Zydis formulation)<br />
Topamax*<br />
Toprol-XL*<br />
Zestril<br />
Toprol-XL*<br />
Topamax*<br />
Zestril*<br />
Toradol<br />
Foradil<br />
Zestril*<br />
t-PA<br />
TNKase<br />
Zetia<br />
Tracleer<br />
Tricor<br />
Zetia<br />
traMADol*<br />
traZODone*<br />
Zetia*<br />
traZODone*<br />
traMADol*<br />
Ziac<br />
TRENtal<br />
TEGretol<br />
Zocor<br />
tretinoin<br />
isotretinoin<br />
Zocor*<br />
Tricor<br />
Tracleer<br />
zolmitriptan<br />
tromethamine<br />
Trophamine<br />
Zonegran<br />
Trophamine<br />
tromethamine<br />
Zostrix<br />
tuberculin purified protein derivative (PPD) influenza virus vaccine<br />
Zovirax<br />
tuberculin purified protein derivative (PPD) tetanus diptheria toxoid (Td)<br />
Zovirax<br />
Tylenol<br />
Tylenol PM<br />
Zyban<br />
Tylenol PM<br />
Tylenol<br />
ZyPREXA<br />
Ultracet<br />
Duricef<br />
ZyPREXA<br />
valacyclovir<br />
valganciclovir<br />
ZyPREXA*<br />
Valcyte<br />
Valtrex<br />
ZyPREXA*<br />
valganciclovir<br />
valacyclovir<br />
ZyPREXA Zydis<br />
Valtrex<br />
Valcyte<br />
ZyrTEC<br />
Varivax<br />
VZIG (varicella-zoster immuneglobulin)<br />
ZyrTEC*<br />
Vexol<br />
Vosol<br />
ZyrTEC*<br />
Viagra<br />
Allegra<br />
ZyrTEC*<br />
vinBLAStine*<br />
vinCRIStine*<br />
ZyrTEC<br />
vinCRIStine*<br />
vinBLAStine*<br />
ZyrTEC-D<br />
Viokase Viokase 8<br />
Zyvox<br />
Viokase 8<br />
Viokase<br />
Zyvox<br />
Vioxx<br />
Zyvox<br />
Viracept<br />
Viramune<br />
Viramune<br />
Viracept<br />
Vosol<br />
Vexol<br />
<strong>Confused</strong> <strong>Drug</strong> Name<br />
Varivax<br />
Wellbutrin XL*<br />
Wellbutrin SR*<br />
Zantac*<br />
Xenical<br />
Xeloda<br />
Yaz<br />
Yasmin<br />
Xanax*<br />
ZyrTEC*<br />
Diabeta*<br />
Zetia<br />
Zestril<br />
ZyPREXA Zydis<br />
Zegerid<br />
Zetia*<br />
ZyPREXA*<br />
Bextra<br />
Zebeta<br />
Zestril*<br />
Tiazac<br />
Cozaar<br />
ZyrTEC*<br />
SUMAtriptan<br />
SINEquan<br />
Zovirax<br />
Zyvox<br />
Zostrix<br />
Diovan<br />
CeleXA<br />
Reprexain<br />
Zestril*<br />
ZyrTEC*<br />
Zelapar (Zydis formulation)<br />
Lipitor<br />
Zantac*<br />
Zocor*<br />
ZyPREXA*<br />
ZyrTEC-D<br />
ZyrTEC<br />
Vioxx<br />
Zovirax<br />
* These drug names are included on TJC’s list <strong>of</strong> look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements <strong>of</strong> the National Patient<br />
Safety Goals. Visit www.jointcommission.org for more information about this TJC requirement.<br />
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other<br />
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication<br />
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at<br />
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),<br />
providing legal protection and confidentiality for patient safety data and error reports it receives.<br />
Institute for Safe<br />
Medication Practices<br />
www.ismp.org<br />
7
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