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.

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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.

2

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.

7

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.

8

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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