Look-Alike Medicines...Use Your Nose to Uncover Mix Ups


Too close for comfort. A mother discovered that her infant daughter had been taking an allergy medicine instead of an antacid for a month. The baby's doctor had prescribed the antacid Zantac (ranitidine) syrup to help with spitting up and crying. When the mother called the pharmacy for a refill, she requested the same grape flavor of medicine that her daughter had been taking.

The pharmacist told her that Zantac did not come in a grape flavor. The mother took the medicine back to the pharmacy. The pharmacist discovered that the label read Zantac but the bottle actually contained Zyrtec (cetirizine), an allergy medicine.

Zantac and Zyrtec have been mixed up frequently because their names look and sound alike. Medicines are often stored alphabetically on pharmacy shelves. So Zantac and Zyrtec also may be right next to each other, making it easy to pick up the wrong bottle. If your child's doctor prescribes either Zantac or Zyrtec syrup, it's a good idea to open the medicine bottle and sniff the contents before you leave the pharmacy. Zantac smells like peppermint and Zyrtec smells like grape candy. It's one more check you can do to help prevent a mistake.

Created on January 1, 2006

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work