ismp list of confused drug names - rx relief
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2020 National Patient Safety Goals Official “Do Not Use” List
ISMP’s List of Confused Drug Names
The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. The Joint Commission’s 2020 National Patient Safety Goals set forth clear guidelines for how healthcare organizations can improve the quality of care. The following pages include:
• Summary of Joint Commission 2020 National Patient Safety Goals (Hospital)*** • Joint Commission’s Official “Do Not Use” List • Institute for Safe Medication Practices (ISMP’s) List of Confused Drug Names
***The exact language of the goals can be found on the Joint Commission Website under 2020 National Patient Safety Goals.
2020 Hospital National Patient Safety Goals
The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them.
This is an easy-to-read document. It has been created for the public. The exact language of the goals can be found at www.jointcommission.org.
Get important test results to the right staff person on time.
Reduce the risk for suicide.
Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
Use proven guidelines to prevent infections that are difficult to treat.
Use proven guidelines to prevent infection of the blood from central lines.
Use proven guidelines to prevent infection after surgery.
Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.
Mark the correct place on the patient’s body where the surgery is to be done.
Pause before the surgery to make sure that a mistake is not being made.
Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. Make sure that the correct patient gets the correct blood when they get a blood transfusion.
Identify patients correctlyNPSG.01.01.01
NPSG.01.03.01
Prevent infectionNPSG.07.01.01
NPSG.07.03.01
NPSG.07.04.01
NPSG.07.05.01
NPSG.07.06.01
Improve staff communicationNPSG.02.03.01
Identify patient safety risksNPSG.15.01.01
Prevent mistakes in surgeryUP.01.01.01
UP.01.02.01
UP.01.03.01
Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.
Take extra care with patients who take medicines to thin their blood.
Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
Use medicines safely
NPSG.03.04.01
NPSG.03.05.01NPSG.03.06.01
Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Use alarms safely
NPSG.06.01.01
©2018 The Joint Commission | May be copied and distributed | Department of Corporate Communications
Official “Do Not Use” List This list is part of the Information Management standards Does not apply to preprogrammed health information
technology systems (i.e. electronic medical records or CPOE systems), but remains under consideration for the future
Organizations contemplating introduction or upgrade of such systems should strive to eliminate the use of dangerous abbreviations, acronyms, symbols and dose designations from the software. Official “Do Not Use” List
Do Not Use Potential Problem Use Instead U, u (unit)
Mistaken for “0”
(zero), the number “4” (four) or “cc”
Write "unit"
IU (International Unit)
Mistaken for IV (intravenous) or the
number 10 (ten)
Write "International Unit"
Q.D., QD, q.d., qd (daily)
Q.O.D., QOD, q.o.d,
qod (every other day)
Mistaken for each other
Period after the Q
mistaken for "I" and the "O" mistaken for "I
Write "daily"
Write "every other day"
Trailing zero (X.0 mg)*
Lack of leading zero (.X mg)
Decimal point is missed
Write X mg Write 0.X mg
MS
MSO4 and MgSO4
Can mean morphine sulfate or magnesium
sulfate
Confused for one another
Write "morphine sulfate"
Write "magnesium sulfate"
1 Applies to all orders and all medication-related documentation that is
handwritten (including free-text computer entry) or on pre-printed forms.
*Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be
used in medication orders or other medication-related documentation. Development of the “Do Not Use” List In 2001, The Joint Commission issued a Sentinel Event Alert on the subject of medical abbreviations. A year later, its Board of Commissioners approved a National Patient Safety Goal requiring accredited organizations to develop and implement a list of abbreviations not to use. In 2004, The Joint Commission created its “Do Not Use” List to meet that goal. In 2010, NPSG.02.02.01 was integrated into the Information Management standards as elements of performance 2 and 3 under IM.02.02.01. 9/18
For more information
• Contact the Standards
Interpretation Group at
630-792-5900.
• Complete the Standards
Online Question Submission
Form.
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
Drug Name Confused Drug NameAbelcet amphotericin BAccupril Aciphex
acetaminophen acetaZOLAMIDEacetaZOLAMIDE acetaminophenacetaZOLAMIDE acetoHEXAMIDE
acetic acid for irrigation glacial acetic acid acetoHEXAMIDE acetaZOLAMIDE
Aciphex AccuprilAciphex AriceptActivase Cathflo ActivaseActivase TNKaseActonel ActosActos Actonel
Adacel (Tdap) Daptacel (DTaP)Adderall InderalAdderall Adderall XR
Adderall XR Adderallado-trastuzumab emtansine trastuzumab
Advair AdvicorAdvicor AdvairAdvicor Altocor
Afrin (oxymetazoline) Afrin (saline)Afrin (saline) Afrin (oxymetazoline)
Aggrastat argatrobanAldara Alora
Alkeran LeukeranAlkeran Myleran
Allegra (fexofenadine) Allegra Anti-Itch Cream(diphenhydrAMINE/allantoin)
Allegra ViagraAllegra Anti-Itch Cream
(diphenhydrAMINE/allantoin) Allegra (fexofenadine)
Alora AldaraALPRAZolam clonazePAM
Drug Name Confused Drug NameALPRAZolam LORazepam
Altocor Advicoramantadine amiodarone
Amaryl ReminylAmbisome amphotericin B
Amicar OmacorAmikin Kineret
aMILoride amLODIPineamiodarone amantadine amLODIPine aMILoride
amphotericin B Abelcetamphotericin B Ambisomeamphotericin B amphotericin B liposomal
amphotericin B liposomal amphotericin BAnacin Anacin-3
Anacin-3 Anacin antacid Atacand
anticoagulant citrate dextrosesolution formula A
anticoagulant sodium citratesolution
anticoagulant sodium citratesolution
anticoagulant citrate dextrosesolution formula A
Antivert AxertAnzemet AvandametApidra Spiriva
Apresoline Priscolineargatroban Aggrastatargatroban Orgaran
Aricept AciphexAricept Azilect
ARIPiprazole proton pump inhibitorsARIPiprazole RABEprazole
Arista AH (absorbable hemostatic agent) ArixtraArixtra Arista AH (absorbable hemostatic agent)Asacol Os-Cal
1
ISMP List of Confused Drug Nameshis list of confused drug names, which includes look-alike andsound-alike name pairs, consists of those name pairs that have
been published in the ISMP Medication Safety Alert!® Acute Care orthe ISMP Medication Safety Alert!® Community/Ambulatory Carenewsletters. Events involving these medications were reported to ISMPthrough either the ISMP National Medication Errors Reporting Program(ISMP MERP) or ISMP National Vaccine Errors Reporting Program (ISMPVERP). We hope you will use this list to determine which medications
require special safeguards to reduce the risk of errors. This may includestrategies such as: using both the brand and generic names on prescrip-tions and labels; including the purpose of the medication on prescrip-tions; configuring computer selection screens to prevent look-alikenames from appearing consecutively; and changing the appearance oflook-alike product names to draw attention to their dissimilarities. Boththe FDA-approved and the ISMP-recommended tall man (mixed case)letters have been included in the list below.
Updated through February 2019
T
Drug Name Confused Drug NameAtacand antacid
atomoxetine atorvastatinatorvastatin atomoxetine
Atrovent Natru-VentAvandamet Anzemet
Avandia PrandinAvandia CoumadinAVINza INVanzAVINza EvistaAxert Antivert
azaCITIDine azaTHIOprineazaTHIOprine azaCITIDine
Azilect AriceptB & O (belladonna and opium) Beano
BabyBIG HBIG (hepatitis B immune globulin)Bayhep-B BayrabBayhep-B Bayrho-D
Bayrab Bayhep-BBayrab Bayrho-D
Bayrho-D Bayhep-BBayrho-D Bayrab
Beano B & O (belladonna and opium)Benadryl benazepril
benazepril BenadrylBenicar Mevacor
Betadine (with povidone-iodine) Betadine (without povidone-iodine)Betadine (without povidone-iodine) Betadine (with povidone-iodine)
betaine (anhydrous form) betaine HClbetaine HCl betaine (anhydrous form)
Bextra ZetiaBicillin C-R Bicillin L-ABicillin L-A Bicillin C-R
Bicitra PolycitraBidex Videx
Brethine MethergineBio-T-Gel T-GelBrevibloc BrevitalBrevital BreviblocBrilinta Brintellix
Brintellix Brilintabuprenorphine HYDROmorphone
buPROPion busPIRonebusPIRone buPROPion
Capadex [non-US product] KapidexCapex KapidexCarac Kuric
Drug Name Confused Drug Namecaptopril carvedilol
carBAMazepine OXcarbazepineCARBOplatin CISplatin
Cardene CardizemCardizem CardeneCardura Coumadin
carvedilol captopril Casodex Kapidex
Cathflo Activase ActivaseCedax Cidex
ceFAZolin cefTRIAXonecefTRIAXone ceFAZolincefuroxime sulfaSALAzineCeleBREX CeleXACeleBREX Cerebyx
CeleXA CeleBREX CeleXA CerebyxCeleXA ZyPREXACerebyx CeleBREXCerebyx CeleXAcetirizine sertralinecetirizine stavudine
chlordiazePOXIDE chlorproMAZINEchlorproMAZINE chlordiazePOXIDEchlorproMAZINE chlorproPAMIDEchlorproPAMIDE chlorproMAZINE
Cidex CedaxCISplatin CARBOplatin
Clarispray (fluticasone propionate) Claritin (loratadine)Claritin (loratadine) Claritin Eye (ketotifen fumarate)Claritin (loratadine) Clarispray (fluticasone propionate)
Claritin-D Claritin-D 24Claritin-D 24 Claritin-D
Claritin Eye (ketotifen fumarate) Claritin (loratadine)Clindesse ClindetsClindets Clindesse
cloBAZam clonazePAMclomiPHENE clomiPRAMINE
clomiPRAMINE clomiPHENEclonazePAM ALPRAZolamclonazePAM cloBAZamclonazePAM cloNIDineclonazePAM cloZAPineclonazePAM LORazepam
cloNIDine clonazePAMcloNIDine cloZAPine
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
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Drug Name Confused Drug NamecloNIDine KlonoPINcloZAPine clonazePAMcloZAPine cloNIDine
Clozaril Colazalcoagulation factor IX (recombinant) factor IX complex, vapor heated
codeine LodineColace CozaarColazal Clozaril
colchicine CortrosynComvax Recombivax HB
Cortrosyn colchicineCoumadin AvandiaCoumadin Cardura
Covaryx HS Covera HSCovera HS Covaryx HS
Cozaar ColaceCozaar ZocorCubicin Cubicin RF
Cubicin RF Cubicin cyclophosphamide cycloSPORINE
cycloSERINE cycloSPORINEcycloSPORINE cyclophosphamidecycloSPORINE cycloSERINEcycloSPORINE cycloSPORINE modified
cycloSPORINE modified cycloSPORINECymbalta Symbyax
dabigatran vigabatrinDACTINomycin DAPTOmycin
Daptacel (DTaP) Adacel (Tdap)DAPTOmycin DACTINomycin
Darvocet PercocetDarvon Diovan
DAUNOrubicin DAUNOrubicin citrate liposomalDAUNOrubicin DOXOrubicinDAUNOrubicin IDArubicin
DAUNOrubicin citrate liposomal DAUNOrubicinDenavir indinavir
Depakote Depakote ERDepakote ER DepakoteDEPO-Medrol SOLU-MedrolDepo-Provera Depo-subQ provera 104
Depo-subQ provera 104 Depo-Proveradesipramine disopyramide
desmopressin vasopressinDesyrel SEROquel
dexamethasone dexmedetomidine
Drug Name Confused Drug NameDexilant DULoxetine
dexmedetomidine dexamethasonedexmethylphenidate dexmethylphenidate mixed saltsdexmethylphenidate methadone
dexmethylphenidate mixed salts dexmethylphenidateDiabenese Diamox
Diabeta ZebetaDiamox Diabenese
diazePAM dilTIAZemDiflucan Diprivan
Dilacor XR PilocarDilaudid Dilaudid-5
Dilaudid-5 DilaudiddilTIAZem diazePAM
dimenhyDRINATE diphenhydrAMINEdiphenhydrAMINE dimenhyDRINATE
Dioval DiovanDiovan DarvonDiovan DiovalDiovan Zyban
Diprivan DiflucanDiprivan Ditropan
disopyramide desipramine Ditropan Diprivan
DOBUTamine DOPamineDOCEtaxel PACLitaxelDOPamine DOBUTamine
Doribax ZoviraxDoxil Paxil
DOXOrubicin DAUNOrubicinDOXOrubicin DOXOrubicin liposomalDOXOrubicin IDArubicin
DOXOrubicin liposomal DOXOrubicinDramamine (dimenhyDRINATE) Dramamine (ginger root)Dramamine (dimenhyDRINATE) Dramamine (meclizine)
Dramamine (ginger root) Dramamine (dimenhyDRINATE)Dramamine (ginger root) Dramamine (meclizine)Dramamine (meclizine) Dramamine (dimenhyDRINATE)Dramamine (meclizine) Dramamine (ginger root)
Dulcolax (bisacodyl) Dulcolax (docusate sodium)Dulcolax (docusate sodium) Dulcolax (bisacodyl)
DULoxetine DexilantDULoxetine FLUoxetineDULoxetine PARoxetine
Durasal DurezolDurezol Durasal
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
3
Drug Name Confused Drug NameDuricef UltracetDynacin DynacircDynacirc Dynacin
edetate calcium disodium edetate disodiumedetate disodium edetate calcium disodium
Effexor Effexor XREffexor XR EffexorEffexor XR Enablex
elvitegravir, cobicistat, emtricitabine, andtenofovir alafenamide
elvitegravir, cobicistat, emtricitabine, andtenofovir disoproxil fumarate
elvitegravir, cobicistat, emtricitabine, andtenofovir disoproxil fumarate
elvitegravir, cobicistat, emtricitabine, andtenofovir alafenamide
Enablex Effexor XREnbrel Levbid
Engerix-B adult Engerix-B pediatric/adolescent Engerix-B pediatric/adolescent Engerix-B adult
Enjuvia JanuviaePHEDrine EPINEPHrineEPINEPHrine ePHEDrineepiRUBicin eriBULin
eriBULin epiRUBicin Estratest Estratest HS
Estratest HS Estratest ethambutol Ethmozine
ethaverine [non-US name] etravirineEthmozine ethambutoletravirine ethaverine [non-US name]
Evista AVINzafactor IX complex, vapor heated coagulation factor IX (recombinant)
Fanapt XanaxFarxiga Fetzima
Fastin (phentermine) Fastin (dietary supplement)Fastin (dietary supplement) Fastin (phentermine)
Femara FemhrtFemhrt Femara
fentaNYL SUFentanilFetzima FarxigaFioricet FiorinalFiorinal Fioricet
flavoxATE fluvoxaMINEFlonase FloventFloranex FlorinefFlorastor FlorinefFlorinef FloranexFlorinef FlorastorFlovent Flonase
Drug Name Confused Drug NamefluPHENAZine fluvoxaMINE
flumazenil influenza virus vaccineFLUoxetine DULoxetineFLUoxetine LoxitaneFLUoxetine PARoxetine
fluvoxaMINE flavoxATEfluvoxaMINE fluPHENAZine
Focalgin B FocalinFocalin Focalgin BFolex Foltx
folic acid folinic acid (leucovorin calcium)folinic acid (leucovorin calcium) folic acid
Foltx Folexfomepizole omeprazole
Foradil ForticalForadil ToradolFortical Foradil
gabapentin gemfibrozilgemfibrozil gabapentingentamicin gentian violet
gentian violet gentamicinglacial acetic acid acetic acid for irrigation
glipiZIDE glyBURIDEGlucotrol Glycotrol
glyBURIDE glipiZIDEGlycotrol GlucotrolGranulex Regranex
guaiFENesin guanFACINEguanFACINE guaiFENesin
HBIG (hepatitis B immune globulin) BabyBIGHealon Hyalganheparin HespanHespan heparin
HMG-CoA reductase inhibitors ("statins") nystatinHumaLOG HumuLINHumaLOG NovoLOG
HumaLOG Mix 75/25 HumuLIN 70/30Humapen Memoir (for use with HumaLOG) Humira Pen
Humira Pen Humapen Memoir (for use with HumaLOG)HumuLIN HumaLOGHumuLIN NovoLIN
HumuLIN 70/30 HumaLOGMix 75/25HumuLIN R U-100 HumuLIN R U-500HumuLIN R U-500 HumuLIN R U-100
Hyalgan HealonhydrALAZINE hydroCHLOROthiazide
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
4
Drug Name Confused Drug NamehydrALAZINE hydrOXYzine
Hydrea LyricahydroCHLOROthiazide hydrALAZINEhydroCHLOROthiazide hydrOXYzine
HYDROcodone oxyCODONEHydrogesic hydrOXYzine
HYDROmorphone buprenorphineHYDROmorphone morphineHYDROmorphone oxyMORphone
hydroxychloroquine hydroxyureaHYDROXYprogesterone medroxyPROGESTERone
hydroxyurea hydroxychloroquinehydroxyurea hydrOXYzinehydrOXYzine hydrALAZINEhydrOXYzine hydroCHLOROthiazidehydrOXYzine HydrogesichydrOXYzine hydroxyureaIDArubicin DAUNOrubicinIDArubicin DOXOrubicinIDArubicin idaruCIZUmab
idaruCIZUmab IDArubicinInderal Adderall
indinavir DenavirinFLIXimab riTUXimab
influenza virus vaccine flumazenilinfluenza virus vaccine perflutren lipid microspheresinfluenza virus vaccine tuberculin purified protein derivative (PPD)
Inspra SpirivaIntuniv InvegaINVanz AVINzaInvega Intuniv iodine LodineIsordil Plendil
ISOtretinoin tretinoinJantoven JanumetJantoven JanuviaJanumet JantovenJanumet JanuviaJanumet SinemetJanuvia EnjuviaJanuvia JantovenJanuvia Janumet
K-Phos Neutral Neutra-Phos-KKaopectate (bismuth subsalicylate) Kaopectate (docusate calcium)
Kaopectate (docusate calcium) Kaopectate (bismuth subsalicylate)Kadian Kapidex
Drug Name Confused Drug NameKaletra KeppraKapidex Capadex [non-US product]Kapidex CapexKapidex CasodexKapidex KadianKay Ciel Kayexalate
Kayexalate Kay CielKeflex KeppraKeppra KaletraKeppra KeflexKetalar ketorolac
ketorolac Ketalarketorolac methadone
Kineret AmikinKlonoPIN cloNIDine
Kuric CaracKwell Qwell
labetalol LaMICtallabetalol lamoTRIgineLaMICtal labetalolLaMICtal LamISILLamISIL LaMICtal
lamiVUDine lamoTRIginelamoTRIgine labetalollamoTRIgine lamiVUDinelamoTRIgine levETIRAcetamlamoTRIgine levothyroxine
Lanoxin levothyroxineLanoxin naloxone
lanthanum carbonate lithium carbonateLantus LatudaLantus LenteLariam LevaquinLasix Luvox
Latuda Lantus Lente Lantus
Letairis Letaris [non-US product]Letaris [non-US product] Letairis
leucovorin calcium Leukeranleucovorin calcium LEVOleucovorin
Leukeran AlkeranLeukeran leucovorin calciumLeukeran MyleranLevaquin Lariam
Levbid EnbrelLevemir Lovenox
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
5
Drug Name Confused Drug NamelevETIRAcetam lamoTRIgine levETIRAcetam levOCARNitinelevETIRAcetam levoFLOXacinlevOCARNitine levETIRAcetamlevoFLOXacin levETIRAcetamLEVOleucovorin leucovorin calcium
levothyroxine lamoTRIginelevothyroxine Lanoxinlevothyroxine liothyronine
Lexapro LoxitaneLexiva Pexeva
linaCLOtide linaGLIPtinlinaGLIPtin linaCLOtideliothyronine levothyroxine
Lipitor LonitenLipitor ZyrTEClithium Ultram
lithium carbonate lanthanum carbonateLodine codeineLodine iodineLoniten Lipitor
Lopressor LyricaLORazepam ALPRAZolamLORazepam clonazePAMLORazepam Lovaza
Lotronex ProtonixLovaza LORazepam
Lovenox LevemirLoxitane FLUoxetine Loxitane LexaproLoxitane SoriataneLunesta Neulasta
Lupron Depot-3 Month Lupron Depot-PedLupron Depot-Ped Lupron Depot-3 Month
Luvox LasixLyrica HydreaLyrica Lopressor
Maalox Maalox Total Stomach ReliefMaalox Total Stomach Relief Maalox
Malarone mefloquineMatulane MaternaMaterna MatulaneMaxzide Microzide
medroxyPROGESTERone HYDROXYprogesteronemedroxyPROGESTERone methylPREDNISolonemedroxyPROGESTERone methylTESTOSTERone
Drug Name Confused Drug Namemefloquine Malaronememantine methadoneMenactra Menomune
Menomune MenactraMephyton methadoneMetadate methadone
Metadate CD Metadate ERMetadate ER Metadate CDMetadate ER methadonemetFORMIN metroNIDAZOLEmethadone dexmethylphenidate methadone ketorolacmethadone memantinemethadone Mephytonmethadone Metadatemethadone Metadate ERmethadone methylphenidatemethadone metOLazoneMethergine Brethine
methazolAMIDE methIMAzolemethazolAMIDE metOLazone
methIMAzole methazolAMIDEmethIMAzole metOLazonemethotrexate metOLazonemethotrexate MTX Patch (lidocaine and menthol)
methylene blue VisionBluemethylphenidate methadone
methylPREDNISolone medroxyPROGESTERonemethylPREDNISolone methylTESTOSTERonemethylTESTOSTERone medroxyPROGESTERonemethylTESTOSTERone methylPREDNISolone
metyraPONE metyroSINEmetyroSINE metyraPONEmetOLazone methadonemetOLazone methazolAMIDEmetOLazone methIMAzolemetOLazone methotrexate
metoprolol succinate metoprolol tartratemetoprolol tartrate metoprolol succinate
metroNIDAZOLE metFORMINMevacor Benicar
Micronase Microzide Microzide MaxzideMicrozide Micronasemidodrine Midrin
Midrin midodrine
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
6
Drug Name Confused Drug NamemiFEPRIStone miSOPROStol
migalastat miglustatmiglustat migalastatMiralax MirapexMirapex Miralax
miSOPROStol miFEPRIStonemitoMYcin mitoXANTRONE
mitoXANTRONE mitoMYcinmitoXANTRONE MTX Patch (lidocaine and menthol)
morphine HYDROmorphonemorphine - non-concentrated oral liquid morphine - oral liquid concentrate
morphine - oral liquid concentrate morphine - non-concentrated oral liquidMotrin Neurontin
MS Contin OxyCONTINMTX Patch (lidocaine and menthol) methotrexateMTX Patch (lidocaine and menthol) mitoXANTRONE
Mucinex (guaiFENesin) Mucinex Allergy (fexofenadine)Mucinex Mucomyst
Mucinex Allergy (fexofenadine) Mucinex (guaiFENesin)Mucinex D Mucinex DM
Mucinex DM Mucinex DMucomyst Mucinex
Myleran AlkeranMyleran Leukeran
nalbuphine naloxonenaloxone Lanoxinnaloxone nalbuphineNarcan Norcuron
Natru-Vent AtroventNavane Norvasc
Neo-Synephrine (oxymetazoline) Neo-Synephrine (phenylephrine)Neo-Synephrine (phenylephrine) Neo-Synephrine (oxymetazoline)
neratinib nilotinibneratinib niraparibNeulasta LunestaNeulasta Nuedexta Neulasta NeumegaNeumega Neulasta Neumega NeupogenNeupogen NeumegaNeurontin MotrinNeurontin Noroxin
Neutra-Phos-K K-Phos NeutralNexAVAR NexIUMNexIUM NexAVAR
niCARdipine NIFEdipine
Drug Name Confused Drug NameniCARdipine niMODipineNIFEdipine niCARdipineNIFEdipine niMODipine
nilotinib neratinibnilotinib niraparib
niMODipine niCARdipineniMODipine NIFEdipine
niraparib neratinibniraparib nilotinibNorcuron Narcan
Normodyne NorpraminNoroxin Neurontin
Norpramin NormodyneNorvasc NavaneNovoLIN HumuLINNovoLIN NovoLOG
NovoLIN 70/30 NovoLOGMix 70/30NovoLOG HumaLOGNovoLOG NovoLIN
NovoLOG Flexpen NovoLOG Mix 70/30 FlexpenNovoLOG Mix 70/30 Flexpen NovoLOG Flexpen
NovoLOG Mix 70/30 NovoLIN 70/30Nuedexta Neulastanystatin HMG-CoA reductase inhibitors ("statins")
Occlusal-HP OcufloxOcuflox Occlusal-HP
OLANZapine QUEtiapineOmacor Amicar
omeprazole fomepizoleopium tincture paregoric (camphorated tincture of opium)
Oracea OrenciaOrencia OraceaOrgaran argatroban
Ortho Tri-Cyclen Ortho Tri-Cyclen LOOrtho Tri-Cyclen LO Ortho Tri-Cyclen
Os-Cal Asacoloxaprozin OXcarbazepine
OXcarbazepine carBAMazepine OXcarbazepine oxaprozin
oxybutynin oxyCODONEoxyCODONE HYDROcodoneoxyCODONE oxybutyninoxyCODONE OxyCONTINoxyCODONE oxyMORphoneOxyCONTIN MS ContinOxyCONTIN oxyCODONE
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
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Drug Name Confused Drug NameOxyCONTIN oxyMORphone
oxyMORphone HYDROmorphoneoxyMORphone oxyCODONEoxyMORphone OxyCONTINPACLitaxel DOCEtaxelPACLitaxel PACLitaxel protein-bound particles
PACLitaxel protein-bound particles PACLitaxelPamelor Panlor DCPamelor Tambocor
Panlor DC Pamelorparegoric (camphorated tincture of opium) opium tincture
PARoxetine DULoxetinePARoxetine FLUoxetinePARoxetine piroxicam
Patanol PlatinolPavulon Peptavlon
Paxil DoxilPaxil PlavixPaxil Taxol
PAZOPanib PONATinibPEMEtrexed PRALAtrexate
penicillin penicillAMINEpenicillAMINE penicillin
Peptavlon PavulonPercocet DarvocetPercocet Procet
perflutren lipid microspheres influenza virus vaccinePexeva Lexiva
PENTobarbital PHENobarbitalPHENobarbital PENTobarbital
Pilocar Dilacor XRpiroxicam PARoxetine
Platinol PatanolPlavix PaxilPlavix Pradax [Non-US Product]Plavix PradaxaPlendil Isordil
pneumococcal 7-valent vaccine pneumococcal polyvalent vaccinepneumococcal polyvalent vaccine pneumococcal 7-valent vaccine
Polycitra Bicitrapolyethylene glycol propylene glycol
PONATinib PAZOPanibpotassium acetate sodium acetatePRALAtrexate PEMEtrexed
Pradax [Non-US Product] PlavixPradaxa Plavix
Drug Name Confused Drug NamePrandin AvandiaPrecare PrecosePrecose Precare
prednisoLONE predniSONEpredniSONE prednisoLONE
Prenexa RanexaPriLOSEC PristiqPriLOSEC PROzacPriscoline Apresoline
Pristiq PriLOSECprobenecid ProcanbidProcan SR ProcanbidProcanbid probenecidProcanbid Procan SR
Procardia XL Protain XLProcet PercocetPrograf ProscarPrograf PROzac
propylene glycol polyethylene glycolpropylthiouracil Purinethol
Proscar PrografProscar Provera
Protain XL Procardia XLprotamine Protonix
proton pump inhibitors ARIPiprazoleProtonix LotronexProtonix protamineProvera ProscarProvera PROzacPROzac PrografPROzac PriLOSECPROzac Provera
Purinethol propylthiouracilPyridium pyridoxine
pyridoxine PyridiumQUEtiapine OLANZapinequiNIDine quiNINEquiNINE quiNIDine
Qwell KwellRABEprazole ARIPiprazole
Ranexa Prenexa raNITIdine riMANTAdine
Rapaflo RapamuneRapamune Rapaflorasageline repaglinideRazadyne Rozerem
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
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Drug Name Confused Drug NameRecombivax HB Comvax
Regranex GranulexReminyl Amaryl Reminyl RobinulRenagel RenvelaRenvela Renagel
repaglinide rasagelineReprexain ZyPREXA
Restoril RisperDALRetrovir ritonavirribavirin riboflavin
riboflavin ribavirinrifabutin rifapentineRifadin Rifater
Rifamate rifAMPinrifAMPin RifamaterifAMPin rifAXIMin
rifapentine rifabutinRifater Rifadin
rifAXIMin rifAMPinriMANTAdine raNITIdine
RisperDAL RestorilRisperDAL rOPINIRole
risperiDONE rOPINIRoleRitalin ritodrine
Ritalin LA Ritalin SRRitalin SR Ritalin LAritodrine Ritalinritonavir RetrovirRituxan Rituxan Hycela
Rituxan Hycela RituxanriTUXimab inFLIXimab
Robinul ReminylromiDEPsin romiPLOStim
romiPLOStim romiDEPsinrOPINIRole RisperDALrOPINIRole risperiDONE
Roxanol Roxicet Roxanol Roxicodone IntensolRoxicet Roxanol
Roxicodone Intensol Roxanol Rozerem RazadyneSalagen selegiline
SandIMMUNE SandoSTATINSandoSTATIN SandIMMUNE
saquinavir SINEquan
Drug Name Confused Drug Namesaquinavir (free base) saquinavir mesylate saquinavir mesylate saquinavir (free base)
Sarafem SerophenesAXagliptin SITagliptinselegiline Salagen
Serophene SarafemSEROquel DesyrelSEROquel SEROquel XRSEROquel SerzoneSEROquel SINEquan
SEROquel XR SEROquelsertraline cetirizinesertraline SoriataneSerzone SEROquelsilodosin sirolimusSinemet JanumetSINEquan saquinavirSINEquan SEROquelSINEquan SingulairSINEquan Zeniquin [veterinary drug]SINEquan ZonegranSingulair SINEquansirolimus silodosinSITagliptin sAXagliptinSITagliptin SUMAtriptan
sodium acetate potassium acetateSolu-CORTEF SOLU-MedrolSOLU-Medrol DEPO-MedrolSOLU-Medrol Solu-CORTEF
Sonata SoriataneSORAfenib SUNItinibSoriatane LoxitaneSoriatane sertralineSoriatane Sonata
sotalol SudafedSpiriva ApidraSpiriva Inspra
stavudine cetirizineSudafed sotalolSudafed Sudafed PE
Sudafed 12 Hour Sudafed 12 Hour Pressure + PainSudafed 12 Hour Pressure + Pain Sudafed 12 Hour
Sudafed PE Sudafed SUFentanil fentaNYL
sulfADIAZINE sulfaSALAzinesulfADIAZINE sulfiSOXAZOLE
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
9
Drug Name Confused Drug NamesulfaSALAzine cefuroximesulfaSALAzine sulfADIAZINEsulfiSOXAZOLE sulfADIAZINESUMAtriptan SITagliptinSUMAtriptan ZOLMitriptanSUNItinib SORAfenibSymbyax Cymbalta
T-Gel Bio-T-Geltacrolimus tamsulosinTambocor Pamelortamsulosin tacrolimusTanzeum ToujeoTanzeum TradjentaTanzeum Tresiba Tanzeum TrulicityTarceva Tresiba
Taxol Paxil Taxol Taxotere
Taxotere TaxolTEGretol TEGretol XRTEGretol Tequin TEGretol TRENtal
TEGretol XR TEGretolTenex XanaxTequin TEGretolTequin Ticlid
Testoderm Testoderm TTSTestoderm Testoderm with Adhesive
Testoderm TTS TestodermTestoderm TTS Testoderm with Adhesive
Testoderm with Adhesive Testoderm Testoderm with Adhesive Testoderm TTS
tetanus diptheria toxoid (Td) tuberculin purified protein derivative (PPD)Thalomid ThiamineThiamine ThalomidtiaGABine tiZANidine
Tiazac ZiacTiclid Tequin
tiZANidine tiaGABineTNKase ActivaseTNKase t-PA (Activase)
Tobradex TobrexTobrex Tobradex
TOLAZamide TOLBUTamideTOLBUTamide TOLAZamide
Topamax Toprol-XL
Drug Name Confused Drug NameToprol-XL TopamaxToradol ForadilToujeo TanzeumToujeo TradjentaToujeo Tresiba Toujeo Trulicity
t-PA (Activase) TNKaseTracleer Tricor
Tradjenta TanzeumTradjenta ToujeoTradjenta TresibaTradjenta TrulicitytraMADol traZODone
trastuzumab ado-trastuzumab emtansinetraZODone traMADolTRENtal TEGretolTresiba TanzeumTresiba TarcevaTresiba ToujeoTresiba TradjentaTresiba Trulicitytretinoin ISOtretinoin
Tricor Tracleertromethamine TrophamineTrophamine tromethamine
Trulicity TanzeumTrulicity ToujeoTrulicity TradjentaTrulicity Tresiba
tuberculin purified protein derivative (PPD) influenza virus vaccinetuberculin purified protein derivative (PPD) tetanus diptheria toxoid (Td)
Tylenol Tylenol PMTylenol PM Tylenol
Ultracet DuricefUltram lithium
valACYclovir valGANciclovirValcyte Valtrex
valGANciclovir valACYclovirValtrex ValcyteVarivax VZIG (varicella-zoster immune globulin)
vasopressin desmopressin Venofer VfendVenofer Vimpat
Vesanoid VesicareVesicare VesanoidVesicare Vessel Care (nutritional supplement)
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
10
Drug Name Confused Drug NameVessel Care (nutritional supplement) Vesicare
Vexol VosolVfend VenoferVfend VimpatViagra AllegraVicodin VisicolVidex Bidex
vigabatrin dabigatranVimpat VenoferVimpat Vfend
vinBLAStine vinCRIStinevinCRIStine vinBLAStine
Viokase Viokase 8Viokase 8 Viokase
Vioxx ZyvoxViracept Viramune
Viramune ViraceptViramune (nevirapine) Viramune (herbal product)
Viramune (herbal product) Viramune (nevirapine)Visicol Vicodin
VisionBlue methylene blueVolumen VoluvenVoluven Volumen
Vosol VexolVZIG (varicella-zoster immune globulin) Varivax
Wellbutrin SR Wellbutrin XLWellbutrin XL Wellbutrin SR
Xanax FanaptXanax TenexXanax ZantacXeloda XenicalXenical XelodaYasmin Yaz
Yaz YasminZantac XanaxZantac ZyrTEC
Zavesca (escitalopram) [non-US product] Zavesca (miglustat)Zavesca (miglustat) Zavesca (escitalopram) [non-US product]
Zebeta DiabetaZebeta Zetia Zegerid Zestril
Zelapar (Zydis formulation) ZyPREXA ZydisZeniquin [veterinary drug] SINEquan
Zerit ZyrTECZestril Zegerid
Drug Name Confused Drug NameZestril ZetiaZestril ZyPREXAZetia BextraZetia ZebetaZetia ZestrilZiac Tiazac
Zocor CozaarZocor ZyrTEC
ZOLMitriptan SUMAtriptanzolpidem ZyloprimZonegran SINEquan
Zostrix ZoviraxZovirax DoribaxZovirax ZostrixZovirax ZyvoxZyban Diovan
Zyloprim zolpidem ZyPREXA CeleXAZyPREXA ReprexainZyPREXA ZestrilZyPREXA ZyrTEC
ZyPREXA Zydis Zelapar (Zydis formulation)ZyrTEC LipitorZyrTEC ZantacZyrTEC ZeritZyrTEC ZocorZyrTEC ZyPREXAZyrTEC ZyrTEC-D
ZyrTEC (cetirizine) ZyrTEC Itchy Eye Drops(ketotifen fumarate)
ZyrTEC -D ZyrTECZyrTEC Itchy Eye Drops
(ketotifen fumarate) ZyrTEC (cetirizine)
Zyvox VioxxZyvox Zovirax
ISMP List of Confused Drug Names
Note: Brand names start with an uppercase letter. Some brand names incorporate tall man letters in initial characters and may not be readily recognized as brandnames. Brand names appear in black; generic names/other products appear in red.
11
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