Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check

Confusion resulting from look-alike and sound-alike drug names and look-alike product packaging can result in potentially harmful medication errors.

A 69-year-old woman admitted to the oncology unit at a 670-bed teaching facility for correction of electrolyte imbalances was mistakenly administered Primacor instead of potassium chloride, reflecting a look-alike packaging medication error.

The medical center developed and implemented process changes, including moving and reorganizing shelf storage bins, enhancing labeling for intravenous medications with similar packaging, tracking and responding to automated dispensing cabinet-filling errors, and revising processes for selecting and maintaining the list of look-alike, sound-alike medications to include the "real time" review of new medications added to the formulary and changes in packaging resulting fron contract changes or drug shortages.

The Joint Commission National Patient Safety Goals for 2005 require organizations to identify and, at a minimum, annually review a list of look-alike sound-alike drugs and to proactively implement safety strategies to help prevent medication errors involving these drug combinations. Proactive assessment of potential for medication errors should include evaluation of potential look-alike packaging problems in addition to the drug names.