Double Trouble: Consumer awareness of look-alike names is critical for drug safety


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 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 below. 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.

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

 è 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. Some doctors can enter the prescription into a computer. This can also make the drug name and dose more legible and 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 get the prescription filled to see a picture of the medicine. That way, you will know what the medicine should look like before you pick up your prescription.

Talk to a pharmacist about the medicine when picking up any new prescription. Read the drug information leaflet that comes with your medicine. Also, you can find a complete list of Confused Drug Names on the Institute for Safe Medication Practices consumer website. It’s certainly not a bad idea to check it out when a new medicine has been prescribed for you or a family member.

Created on January 1, 2010

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