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Reporting a Medication Error

Double Trouble: Consumer Awareness of Look-Alike Names is Critical for Drug Safety

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Republished October 21, 2024

Coming up with a name for a new medicine isn’t as easy as you think. Drug companies look for names that scream ‘take me’ to fix what ails you. The name also needs to stick in your doctor’s mind so it is easy to remember.

With so many medicines already on the market, drug companies and the US Food and Drug Administration (FDA) go to great lengths to avoid names that look or sound like other medicines. However, problems with medicine names that look and sound alike still occur.

In fact, one of the most common forms of medication errors reported to us involves confusion between two drugs with similar names. The problem can occur when you get a prescription filled. If your doctor writes a prescription for a medicine, it may look similar to the name of another medicine. For example, look at the handwritten prescription in Figure 1. What is the name of the medicine that is being prescribed? Is it Avandia (rosiglitazone), a medicine to treat diabetes, or Coumadin (warfarin), a blood thinner? It could be either. (The brand name drug Coumadin is no longer available, but it was so common that most people still refer to it.)

coumadin
Figure 1. A handwritten prescription for a medicine can be misread as a different medicine. This example is for the medicine Avandia, but was misread as Coumadin.

When typewritten, Avandia and Coumadin look very different. But when handwritten, especially in cursive, the names can look remarkably alike.

Here's what you can do: Most medicines with names that look or sound like other medicines are not used to treat the same condition. So, asking your doctor to list the reason for the medicine on the prescription will help your pharmacist provide the correct medicine. You can also make sure the pharmacist knows the reason you are taking a medicine. Nowadays, doctors can enter the prescription into a computer and it is sent directly to your pharmacy. This makes the drug name and dose more legible and can reduce confusion between look-alike names.

When you fill a prescription, look at the medicine and label on the vial before you leave the pharmacy to be sure it looks right. If the prescription is new, you can type in the medicine’s name on Google Images before you pick up the prescription to see a picture of the medicine. That way, you will know what the medicine should look like before you pick up your prescription. Make sure you also look at the medicine dose (i.e., 5 mg, 10 mg) to make sure it is correct.

Talk to a pharmacist about the medicine when picking up any new prescription. Read the drug information leaflet that comes with your medicine.

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