Perhaps you have squirted a yellow packet of lemon juice onto your hot dog thinking it was mustard instead. Sometimes such mistakes are funny or just annoying – sometimes they can be very serious. Similar Look-Alike or Sound-Alike occurrences have happened quite often in healthcare. For example, a patient may mistakenly receive an incorrect medication that appeared proper at the time. Fortunately, research has been able to determine and prevent multiple factors that contribute to errors of all types and in all places – and these also have great application in everyday living.
For example – Where you store something matters!
In healthcare, we learned NOT to store medications alphabetically or adjacent to medications with similar names, packaging, or actions. As an example why, consider this – In an attempt to keep bug spray away from grand children, you put it in a higher cabinet, out of reach, and right next to the cooking oil spray. Can you see the chance for a very bad (albeit insect-free) meal at some point?
Look-alikes can be readily thought to be something they definitely are not. For example – chocolate laxatives have been confused with candy, some mothballs have been mistaken for mini-marshmallows, a tube of hydro-cortisone cream resembles toothpaste, a few decongestant over the counter medications are very difficult to distinguish from red hot cake decorations, windshield washer fluid looks like several blue drinks for kids, animal crackers are fed to Fido instead of dog biscuits, and liquid pine cleaner has been accidentally poured in place of apple juice. To prevent these Look-Alike mistakes, separate and store these items in very different places – away from each other and in the case of hazardous items, not easily accessible to children – or pets!
Look-Alikes, Sound-Alikes, and Spelled-Alikes are EVERYWHERE
Here are just a few:
- Buy by today – or bye!
- Is yelling allowed aloud?
- Is it their, they’re – and over there!
- I cited the site about sight.
- The dove dove into the bush.
- Farmers produce the produce.
- The insurance is invalid for the invalid.
Now, consider the challenges for those with poor vision, low literacy skills, limited attention spans, or whose primary language is not English! How important are labels, colors, and container differences when assuming the contents?
There are also cultural considerations
For example, “once” in English is one time – while in Spanish “once” means eleven! Think of the potential for overdose with medications when translating directions on this one!
Look-Alikes and Sound-Alikes are Common with Medications
There are limits to language – and we are running low on new letters and unique names for medications. For example – Several years ago, a new medication became available to treat peptic ulcers and gastric reflux. Losec was widely used until several incidents occurred where it was confused with a very different drug – Lasix (a diuretic to reduce fluid in the body). The makers of Losec recognized this hazard and changed the name to Prilosec to reduce the potential for error.
Here are just some of many other medications at risk of being easily confused:
HumaLOG versus HumuLIN (Both are insulin, but with different onset and duration times.)
CeleXA and CeleBREX (Celexa is an antidepressant. Celebrex is an anti-inflammatory drug.)
You may have noticed that parts of these drug names are in capital
letters. Tall Man Letters were incorporated into similar drug names in an effort to point out differences in spelling. If you see a drug name with Tall Man Letters, be aware there is likely something else available that has potential to be confused with it!
What to do
- Be aware of the potential for unintentional misinterpretation!
- Write it down and read it back when receiving important information.
- Request others write down and read back information from you (Pizza delivery orders come to mind here!)
- Always check your medications before leaving the pharmacy – and ask questions if you are unsure about something. This especially important as medication manufacturers may change color and size of tablets without notice to you!
- Do not store very dissimilar but similar looking items together (such as Lysol next to the Listerine under the bathroom sink or cans of tuna fish with cans of cat food).
Here is a list of Look-Alike drug names from ISMP (Institute for Safe Medication Practices)
Also take a look at the Upstate New York Poisons Center at:
The national toll-free “Poison Help” telephone number: 1-800-222-1222. Regardless of your location in the U.S. or its territories, dialing that number will direct your call to the nearest regional poison center.