As if pharmaceutical medications aren’t hard enough to pronounce and differentiate, we also need to recognize medications with similar-appearing names.
Take these two for example: Diphenhydramine and Dimenhydrinate
If you squinted at the screen thinking, what the fu… don’t worry! I did too!
Part of your PTCB exam tests your ability to recognize look-alike-sound-alike medications and ways to emphasize differences between the words to prevent medication errors.
Look-alike-sound-alike (LASA) medications have names that look or sound similar enough to another medication that errors could arise due to their similarity.
LASA errors are estimated to be 6.2–14.7% of all medication errors, which is why identifying and adjusting accordingly prevents the issue before it happens. Further, an estimated 251,000 people die every year due to medication errors, making it crucial to catch errors before they occur.
But if we can’t change the medication names, how do we counter this?
Tall-man lettering is a common way to prevent errors. Once a LASA medication is identified, the portion of each name that has the most significant difference is capitalized. Let’s use the example from earlier…
diphenhydrAMINE and dimenhyDRINATE
Notice the difference? It’s much easier to catch now!
LASA Medications using tall man lettering
| Drug Name… | Confused with… |
| acetaZOLAMIDE | acetoHEXAMIDE |
| buPROPion | busPIRone |
| chlorproMAZINE | chlorproPAMIDE |
| clomiPHENE | clomiPRAMINE |
| cycloSERINE | cycloSPORINE |
| DAUNOrubicin | DOXOrubicin |
| dimenhyDRINATE | diphenhydrAMINE |
| DOBUTamine | DOPamine |
| hydrALAZINE | hydrOXYzine |
| methylPREDNISolone | methylTESTOSTERone |
| TOLAZamide | TOLBUTamide |
Other ways to avoid LASA mistakes
Pharmacies will also implement ways to prevent errors beyond tall-man lettering. These have been recommended by the Institute of Safe Medication Practices (ISMP) to act as a guide
Use barcodes when filling and stocking or checking inventory counts. By scanning each unique barcode on the medication bottle, you can verify you have the correct medication needed for your count.
Do not fill multiple prescriptions and scan the barcodes on the bottle afterward; maintain that the process is scan, verify, then count
When filling a large prescription and several bottles of the same medication are needed to fulfill the order, scan each separate bottle before counting. Despite the redundancy, it helps prevent possible errors
Verify the National Drug Code (NDC) before filling, which is unique to the medication and its pill count. This is an extra safety measure you can take to prevent possible errors
Research errors and risks that have been caught in other pharmacies. This keeps you informed as a technician and keeps the patients safe
Sources
ISMP Recommended Safety measures