Institute for Safe Medication Practices

ISMPs List of Confused Drug Names

his list of confused drug names, which includes look-alike and sound-alike name pairs, consists only of those name pairs that have been involved in medication errors published in the ISMP Medication Safety Alert! The errors involving these medications were reported to ISMP through the USP-ISMP Medication Errors Reporting Program (MERP).
Drug Name ABELCET** ACCUPRIL acetazolamide** acetohexamide** ACIPHEX ACIPHEX ACTIVASE ACTONEL ACTOS ADDERALL ADVICOR AGGRASTAT ALDARA ALKERAN ALLEGRA ALORA ALTOCOR AMARYL** AMBISOME** AMIKIN amphotericin B** amphotericin B** antacid ANTIVERT ANZEMET APRESOLINE argatroban argatroban ARICEPT aripiprazole aripiprazole ASACOL ATACAND ATROVENT AVANDAMET AVANDIA AVANDIA** AVINZA AVINZA**

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established a National Patient Safety Goal that requires each accredited organization to identify a list of look-alike or sound-alike drugs used in the organization. Those names that appear on the JCAHO's list of look-alike or sound-alike names have been noted with a double asterisk (**) below.
ISMP Medication Safety Alert! Acute Care Edition Vol. 8, Issue 13, 6/26/03 Vol. 5, Issue 9, 5/3/00 Vol. 5, Issue 12, 6/14/00 Vol. 5, Issue 12, 6/14/00 Vol. 5, Issue 24, 11/29/00 Vol. 5, Issue 9, 5/3/00 Vol. 8, Issue 11, 5/29/03 Vol. 9, Issue 13, 7/1/04 Vol. 9, Issue 13, 7/1/04 Vol. 1, Issue 4, 2/28/96 Vol. 7, Issue 9, 5/1/02 Vol. 6, Issue 15, 7/25/01 Vol. 2, Issue 14, 7/16/97 Vol. 5, Issue 1, 1/12/00 Vol. 3, Issue 12, 6/17/98 Vol. 2, Issue 14, 7/16/97 Vol. 7, Issue 9, 5/1/02 Vol. 9, Issue 18, 9/9/04 Vol. 8, Issue 13, 6/26/03 Vol. 7, Issue 13, 6/26/02 Vol. 8, Issue 13, 6/26/03 Vol. 8, Issue 13, 6/26/03 Vol. 4, Issue 25, 12/15/99 Vol. 7, Issue 21, 10/16/02 Vol. 7, Issue 22, 10/30/02 Vol. 6, Issue 22, 10/31/01 Vol. 6, Issue 15, 7/25/01 Vol. 7, Issue 4, 2/20/02 Vol. 5, Issue 24, 11/29/00 Vol. 8, Issue 5, 6/26/03 Vol. 8, Issue 8, 4/17/03 Vol. 2, Issue 5, 3/12/97 Vol. 4, Issue 25, 12/15/99 Vol. 4, Issue 22, 11/3/99 Vol. 7, Issue 22, 10/30/02 Vol. 4, Issue 18, 9/8/99 Vol. 5, Issue 15, 7/26/00 Vol. 7, Issue 10, 5/15/02 Vol. 9, Issue 5, 3/11/04

Updated 4/1/05 ISMP 2005

Confused Drug Name amphotericin B** ACIPHEX acetohexamide** acetazolamide** ARICEPT ACCUPRIL TNKase ACTOS ACTONEL INDERAL ALTOCOR argatroban ALORA LEUKERAN VIAGRA ALDARA ADVICOR REMINYL** amphotericin B** KINERET ABELCET** AMBISOME** ATACAND AXERT AVANDAMET PRISCOLINE AGGRASTAT ORGARAN ACIPHEX proton pump inhibitors rabeprazole OS-CAL antacid NATRU-VENT ANZEMET PRANDIN COUMADIN** INVANZ EVISTA**

** These drug names are included on the JCAHO's list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jcaho.org for more information about this JCAHO requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters wishes as to the level of detail included in publication.

Institute for Safe Medication Practices

www.ismp.org

Institute for Safe Medication Practices

ISMPs List of Confused Drug Names

Drug Name AXERT BabyBIG BAYHEP-B BAYRAB BAYRHO-D BICILLIN C-R BICILLIN L-A BRETHINE camphorated tincture of opium (paregoric) carboplatin** CEDAX CELEBREX** CELEXA CELEXA** CEREBYX** CIDEX cisplatin** CLARITIN-D CLARITIN-D 24 CLOZARIL COLACE COLAZAL colchicine COMVAX CORTROSYN COUMADIN** COZAAR COZAAR dactinomycin daptomycin DARVON daunorubicin** daunorubicin** DENAVIR DEPAKOTE DEPOKOTE ER DEPO-MEDROL DIABINESE DIABETA** DIAMOX DIATEX (diazepam in Mexico) DIATX DILACOR XR DILAUDID DILAUDID-5 DIOVAL Confused Drug Name ANTIVERT HBIG BAYRAB BAYRHO-D BAYHEP-B BICILLIN L-A BICILLIN C-R METHERGINE opium tincture cisplatin** CIDEX CELEXA** ZYPREXA CELEBREX** CELEXA** CEDAX carboplatin** CLARITIN-D 24 CLARITIN-D COLAZAL COZAAR CLOZARIL CORTROSYN RECOMBIVAX HB colchicine AVANDIA** COLACE ZOCOR daptomycin dactinomycin DIOVAN idarubicin** daunorubicin citrate liposomal** indinavir DEPOKOTE ER DEPAKOTE SOLU-MEDROL DIAMOX ZEBETA** DIABINESE DIATX DIATEX (diazepam in Mexico) PILOCAR DILAUDID-5 DILAUDID DIOVAN

Updated 4/1/05 ISMP 2005

ISMP Medication Safety Alert! Acute Care Edition Vol. 7, Issue 21, 10/16/02 Vol. 10, Issue 6, 3/24/05 Vol. 2, Issue 4, 2/26/97 Vol. 2, Issue 4, 2/26/97 Vol. 2, Issue 4, 2/26/97 Vol. 9, Issue 6, 3/25/04 Vol. 9, Issue 6, 3/25/04 Vol. 9, Issue 21, 10/21/04 Vol. 7, Issue 4, 2/20/02 Vol. 1 Issue 22, 11/06/96 Vol. 2, Issue 2, 1/29/97 Vol. 4, Issue 9, 5/5/99 Vol. 3, Issue 18, 9/9/98 Vol. 4, Issue 9, 5/5/99 Vol. 4, Issue 3, 2/10/99 Vol. 2, Issue 2, 1/29/97 Vol. 1 Issue 22, 11/06/96 Vol. 1, Issue 25, 12/18/96 Vol. 1, Issue 25, 12/18/96 Vol. 6, Issue 9, 5/2/01 Vol. 1, Issue 23, 11/20/96 Vol. 6, Issue 9, 5/2/01 Vol. 5, Issue 2, 2/9/00 Vol.8 , Issue 6, 3/20/03 Vol. 5, Issue 2, 2/9/00 Vol. 5, Issue 15, 7/26/00 Vol. 1, Issue 23, 11/20/96 Vol. 1, Issue 1, 1/15/96 Vol. 8, Issue 22, 10/30/03 Vol. 8, Issue 22, 10/30/03 Vol. 2, Issue 19, 9/24/97 Vol. 6, Issue 22, 10/31/01 Special Alert, 8/18/98 Vol. 2, Issue 13, 7/2/97 Vol. 6, Issue 3, 2/7/01 Vol. 6, Issue 3, 2/7/01 Vol. 8, Issue 11, 5/29/03 Vol. 5, Issue 14, 7/14/00 Vol. 5, Issue 18, 9/6/00 Vol. 5, Issue 14, 7/14/00 Vol. 7, Issue 16, 8/7/02 Vol. 7, Issue 16, 8/7/02 Vol. 2, Issue 15, 7/30/97 Vol. 1, Issue 13, 7/3/96 Vol. 1, Issue 13, 7/3/96 Vol. 2, Issue 19, 9/24/97

** These drug names are included on the JCAHO's list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jcaho.org for more information about this JCAHO requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters wishes as to the level of detail included in publication.

Institute for Safe Medication Practices

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Institute for Safe Medication Practices

ISMPs List of Confused Drug Names

Drug Name DIOVAN DIOVAN DIOVAN DIPRIVAN DITROPAN dobutamine dopamine doxorubicin hydrochloride** DURICEF ENBREL ENDOCET ENGERIX-B adult ENGERIX-B pediatric/adolescent ephedrine** epinephrine** ESTRATEST ESTRATEST HS ethambutol ETHMOZINE EVISTA** FEMARA FEMHRT fentanyl** flavoxate fluvoxamine FOLEX FOLTX folic acid** folinic acid (leucovorin calcium)** FORADIL gentamicin gentian violet GRANULEX HBIG HEALON heparin** HESPAN** HUMALOG** HUMALOG MIX 75/25** HUMULIN** HUMULIN 70/30** HYALGAN HYDROGESIC hydromorphone** hydroxyzine idarubicin** Confused Drug Name DIOVAL ZYBAN DARVON DITROPAN DIPRIVAN dopamine dobutamine doxorubicin liposomal** ULTRACET LEVBID INDOCID ENGERIX-B pediatric/adolescent ENGERIX-B adult epinephrine** ephedrine** ESTRATEST HS ESTRATEST ETHMOZINE ethambutol AVINZA** FEMHRT FEMARA sufentanil** fluvoxamine flavoxate FOLTX FOLEX folinic acid (leucovorin calcium)** folic acid** TORADOL gentian violet gentamicin REGRANEX BabyBIG HYALGAN HESPAN** heparin** HUMULIN** HUMULIN 70/30** HUMALOG** HUMALOG MIX 75/25** HEALON hydroxyzine morphine** HYDROGESIC daunorubicin**

Updated 4/1/05 ISMP 2005

ISMP Medication Safety Alert! Acute Care Edition Vol. 2, Issue 19, 9/24/97 Vol. 2, Issue 19, 9/24/97 Vol. 2, Issue 19, 9/24/97 Vol. 7, Issue 6, 3/20/02 Vol. 7, Issue 6, 3/20/02 Vol. 1, Issue 15, 7/31/96 Vol. 1, Issue 15, 7/31/96 Vol. 9, Issue 14, 7/15/04 Vol. 7, Issue 6, 3/20/02 Vol. 7, Issue 19, 9/18/02 Vol. 8, Issue 22, 10/30/03 Vol. 7, Issue 1, 1/5/02 Vol. 7, Issue 1, 1/5/02 Vol. 8, Issue 8, 4/17/03 Vol. 8, Issue 8, 4/17/03 Vol. 1, Issue 19, 9/25/96 Vol. 1, Issue 19, 9/25/96 Vol. 4, Issue 20, 10/6/99 Vol. 4, Issue 20, 10/6/99 Vol. 9, Issue 5, 3/11/04 Vol. 7, Issue 7, 4/3/02 Vol. 7, Issue 7, 4/3/02 Vol. 6, Issue 3, 2/7/01 Vol. 10, Issue 4, 2/24/05 Vol. 10, Issue 4, 2/24/05 Vol. 10, Issue 2, 1/27/05 Vol.10, Issue 2, 1/27/05 Vol. 8, Issue 20, 10/2/03 Vol. 8, Issue 20, 10/2/03 Vol. 7, Issue 12, 6/12/02 Vol. 3, Issue 21, 10/21/98 Vol. 3, Issue 21, 10/21/98 Vol. 3, Issue 9, 5/6/98 Vol. 10, Issue 6, 3/24/05 Vol. 9, Issue 9, 5/6/04 Vol. 4, Issue 18, 9/8/99 Vol. 4, Issue 18, 9/8/99 Vol. 7, Issue 8, 4/17/02 Vol. 7, Issue 24, 11/27/02 Vol. 7, Issue 8, 4/17/02 Vol. 7, Issue 24, 11/27/02 Vol. 9, Issue 9, 5/6/04 Vol. 7, Issue 4, 2/20/02 Vol. 9, Issue 12, 7/01/04 Vol. 7, Issue 4, 2/20/02 Vol. 6, Issue 22, 10/31/01

** These drug names are included on the JCAHO's list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jcaho.org for more information about this JCAHO requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters wishes as to the level of detail included in publication.

Institute for Safe Medication Practices

www.ismp.org

Institute for Safe Medication Practices

ISMPs List of Confused Drug Names

Drug Name INDERAL indinavir INDOCID infliximab influenza virus vaccine INSPRA INVANZ iodine ISORDIL isotretinoin K-PHOS NEUTRAL KALETRA KEPPRA KETALAR ketorolac KINERET LAMICTAL** LAMISIL** lamivudine lamotrigine LANOXIN LANTUS** LASIX LENTE** leucovorin calcium** LEUKERAN LEVBID levothyroxine LEXAPRO LIPITOR liposomal doxorubicin (DOXIL) LODINE LOTRONEX LOXITANE LUPRON DEPOT-3 MONTH LUPRON DEPOT-PED LUVOX MAXZIDE METADATE METADATE CD METADATE ER METADATE ER METFORMIN methadone methadone METHERGINE Confused Drug Name ADDERALL DENAVIR ENDOCET rituximab tuberculin purified protein derivative (PPD) SPIRIVA AVINZA LODINE PLENDIL tretinoin NEUTRA-PHOS-K KEPPRA KALETRA ketorolac KETALAR AMIKIN LAMISIL** LAMICTAL** lamotrigine lamivudine levothyroxine LENTE** LUVOX LANTUS** LEUKERAN** MYLERAN ENBREL LANOXIN LOXITANE ZYRTEC doxorubicin hydrochloride iodine PROTONIX LEXAPRO LUPRON DEPOT-PED LUPRON DEPOT-3 MONTH LASIX MICROZIDE methadone METADATE ER METADATE CD methadone metronidazole METADATE ER METADATE BRETHINE

Updated 4/1/05 ISMP 2005

ISMP Medication Safety Alert! Acute Care Edition Vol. 1, Issue 4, 2/28/96 Vol. 2, Issue 13, 7/2/97 Vol. 8, Issue 22, 10/30/03 Vol. 9, Issue 3, 2/12/04 Vol. 9, Issue 22, 11/4/04 Vol. 10, Issue 4, 2/24/05 Vol. 7, Issue 10, 5/15/02 Vol. 7, Issue 14, 7/10/02 Vol. 4, Issue 22, 11/3/99 Vol. 1, Issue 22, 11/6/96 Vol. 7, Issue 4, 2/20/02 Vol. 8, Issue 22, 10/30/03 Vol. 8, Issue 22, 10/30/03 Vol. 3, Issue 24, 12/2/98 Vol. 3, Issue 24, 12/2/98 Vol. 7, Issue 13, 6/26/02 Vol. 3, Issue 12, 6/17/98 Vol. 3, Issue 12, 6/17/98 Vol. 1, Issue 18, 9/11/96 Vol. 1, Issue 18, 9/11/96 Vol. 5, Issue 18, 9/6/00 Vol. 6, Issue 16, 8/8/01 Vol. 1, Issue 3, 2/14/96 Vol. 6, Issue 16, 8/8/01 Vol. 8, Issue 20, 10/2/03 Vol. 5, Issue 1, 1/12/00 Vol. 7, Issue 19, 9/18/02 Vol. 5, Issue 18, 9/6/00 Vol. 8, Issue 25, 12/18/03 Vol. 8, Issue 7, 4/4/03 Vol. 9, Issue 14, 7/15/04 Vol. 7, Issue 14, 7/10/02 Vol. 5, Issue 24, 11/29/00 Vol. 8, Issue 25, 12/18/03 Vol. 7, Issue 18, 9/4/02 Vol. 7, Issue 18, 9/4/02 Vol. 1, Issue 3, 2/14/96 Vol. 2, Issue 9, 5/7/97 Vol.8 , Issue 13, 6/26/03 Vol. 6, Issue 24, 11/28/01 Vol. 6, Issue 24, 11/28/01 Vol. 6, Issue 4, 2/21/01 Vol. 9, Issue 20, 10/7/04 Vol. 6, Issue 4, 2/21/01 Vol.8 , Issue 13, 6/26/03 Vol. 9, Issue 21, 10/21/04

** These drug names are included on the JCAHO's list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jcaho.org for more information about this JCAHO requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters wishes as to the level of detail included in publication.

Institute for Safe Medication Practices

www.ismp.org

Institute for Safe Medication Practices

ISMPs List of Confused Drug Names

Drug Name methimazole metolazone metronidazole MICRONASE MICROZIDE MICROZIDE mifepristone MIRALAX MIRAPEX misoprostol morphine** morphine - oral liquid concentrate** MS CONTIN MUCINEX MUCOMYST MYLERAN NARCAN NATRU-VENT NAVANE NEULASTA NEUMEGA NEUMEGA NEUPOGEN NEURONTIN NEUTRA-PHOS-K NORCURON NOROXIN NORVASC NOVOLIN 70/30** NOVOLOG MIX 70/30** OCCLUSAL-HP OCUFLOX opium tincture ORGARAN OS-CAL oxycodone OXYCONTIN OXYCONTIN paclitaxel
Updated 4/1/05 ISMP 2005

Confused Drug Name metolazone methimazole METFORMIN MICROZIDE MAXZIDE MICRONASE misoprostol MIRAPEX MIRALAX mifepristone hydromorphone** morphine - non-concentrated oral liquid** OXYCONTIN MUCOMYST MUCINEX ALKERAN NORCURON ATROVENT NORVASC NEUMEGA NEUPOGEN NEULASTA NEUMEGA NOROXIN K-PHOS NEUTRAL NARCAN NEURONTIN NAVANE NOVOLOG MIX 70/30** NOVOLIN 70/30** OCUFLOX OCCLUSAL-HP camphorated tincture of opium (paregoric) argatroban ASACOL OXYCONTIN MS CONTIN oxycodone
paclitaxel protein-bound particles for injectable suspension paclitaxel PANLOR DC PAMELOR PLATINOL PEPTAVLON TAXOL PLAVIX

paclitaxel protein-bound particles for injectable suspension

PAMELOR PANLOR DC PATANOL PAVULON PAXIL PAXIL

ISMP Medication Safety Alert! Acute Care Edition Vol. 9, Issue 22, 11/4/04 Vol. 9, Issue 22, 11/4/04 Vol. 9, Issue 20, 10/7/04 Vol. 2, Issue 9, 5/7/97 Vol. 2, Issue 9, 5/7/97 Vol. 2, Issue 9, 5/7/97 Vol. 7, Issue 15, 7/24/02 Vol. 7, Issue 20, 10/3/02 Vol. 7, Issue 20, 10/3/02 Vol. 7, Issue 15, 7/24/02 Vol. 9, Issue 12, 7/01/04 Vol. 1, Issue 25, 12/18/96 Vol. 6, Issue 17, 8/22/01 Vol. 9, Issue 13, 7/1/04 Vol. 9, Issue 13, 7/1/04 Vol. 5, Issue 1, 1/12/00 Vol. 3, Issue 20, 10/7/98 Vol. 4, Issue 22, 11/3/99 Vol. 9, Issue 7, 4/8/04 Vol. 9, Issue 8, 4/22/04 Vol. 4, Issue 5, 3/10/99 Vol. 9, Issue 8, 4/22/04 Vol. 4, Issue 5, 3/10/99 Vol. 7, Issue 3, 2/06/02 Vol. 7, Issue 4, 2/20/02 Vol. 3, Issue 20, 10/7/98 Vol. 7, Issue 3, 2/06/02 Vol. 9, Issue 7, 4/8/04 Vol. 9, Issue 14, 7/15/04 Vol. 9, Issue 14, 7/15/04 Vol. 6, Issue 11, 5/30/01 Vol. 6, Issue 11, 5/30/01 Vol. 7, Issue 4, 2/20/02 Vol. 7, Issue 4, 2/20/02 Vol. 2, Issue 5, 3/12/97 Vol. 6, Issue 17, 8/22/01 Vol. 6, Issue 17, 8/22/01 Vol. 6, Issue 17, 8/22/01 Vol. 10, Issue 5, 3/10/05 Vol. 10, Issue 5, 3/10/05 Vol. 6, Issue 18, 9/5/01 Vol. 6, Issue 18, 9/5/01 Vol. 2, Issue 1, 1/15/97 Vol. 2, Issue 7, 4/9/97 Vol. 2, Issue 1, 1/15/97 Vol. 7, Issue 12, 6/12/02

** These drug names are included on the JCAHO's list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jcaho.org for more information about this JCAHO requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters wishes as to the level of detail included in publication.

Institute for Safe Medication Practices

www.ismp.org

Institute for Safe Medication Practices

ISMPs List of Confused Drug Names

Drug Name PEPTAVLON PERCOCET PILOCAR PLATINOL PLAVIX PLENDIL pneumococcal 7-valent vaccine pneumococcal polyvalent vaccine PRANDIN PRECARE PRECOSE PRILOSEC PRISCOLINE probenecid PROCANBID PROCARDIA XL PROCET propylthiouracil PROTAIN XL protamine Proton Pump Inhibitors PROTONIX PROTONIX PROZAC PURINETHOL quinine quinidine rabeprazole RECOMBIVAX HB REGRANEX REMINYL REMINYL** RETROVIR** RIFATER RIFADIN RITALIN RITALIN LA RITALIN SR ritodrine ritonavir** rituximab ROBINUL ROXANOL ROXANOL ROXICET ROXICODONE INTENSOL Confused Drug Name PAVULON PROCET DILACOR XR PATANOL PAXIL ISORDIL pneumococcal polyvalent vaccine pneumococcal 7-valent vaccine AVANDIA PRECOSE PRECARE PROZAC APRESOLINE PROCANBID probenecid PROTAIN XL PERCOCET PURINETHOL PROCARDIA XL PROTONIX aripiprazole LOTRONEX protamine PRILOSEC propylthiouracil quinidine quinine aripiprazole COMVAX GRANULEX ROBINUL AMARYL** ritonavir** RIFADIN RIFATER ritodrine RITALIN SR RITALIN LA RITALIN RETROVIR** infliximab REMINYL ROXICODONE INTENSOL ROXICET ROXANOL ROXANOL

Updated 4/1/05 ISMP 2005

ISMP Medication Safety Alert! Acute Care Edition Vol. 2, Issue 7, 4/9/97 Vol. 6, Issue 18, 9/5/01 Vol. 2, Issue 15, 7/30/97 Vol. 2, Issue 1, 1/15/97 Vol. 7, Issue 12, 6/12/02 Vol. 4, Issue 22, 11/3/99 Vol. 7, Issue 10, 5/15/02 Vol. 7, Issue 10, 5/15/02 Vol. 4, Issue 18, 9/8/99 Vol. 1, Issue 19, 9/25/96 Vol. 1, Issue 19, 9/25/96 Vol. 1, Issue 17, 8/28/96 Vol. 6, Issue 22, 10/31/01 Vol. 5, Issue 5, 3/8/00 Vol. 5, Issue 5, 3/8/00 Vol. 5, Issue 20, 10/4/00 Vol. 6, Issue 18, 9/5/01 Vol. 8, Issue 17, 8/21/03 Vol. 5, Issue 20, 10/4/00 Vol. 9, Issue 6, 3/25/04 Vol. 8, Issue 5, 6/26/03 Vol. 5, Issue 24, 11/29/00 Vol. 9, Issue 6, 3/25/04 Vol. 1, Issue 17, 8/28/96 Vol. 8, Issue 17, 8/21/03 Vol. 2, Issue 20, 10/8/97 Vol. 2, Issue 20, 10/8/97 Vol. 8, Issue 8, 4/17/03 Vol.8 , Issue 6, 3/20/03 Vol. 3, Issue 9, 5/6/98 Vol. 7, Issue 4, 2/20/02 Vol. 9, Issue 18, 9/9/04 Vol. 5, Issue 20, 10/4/00 Vol. 6, Issue 24, 11/28/01 Vol. 6, Issue 24, 11/28/01 Vol. 2, Issue 10, 5/21/97 Vol. 6, Issue 24, 11/28/01 Vol. 6, Issue 24, 11/28/01 Vol. 2, Issue 10, 5/21/97 Vol. 5, Issue 20, 10/4/00 Vol. 9, Issue 3, 2/12/04 Vol. 7, Issue 4, 2/20/02 Vol. 1, Issue 25, 12/18/96 Vol. 1, Issue 25, 12/18/96 Vol. 1, Issue 25, 12/18/96 Vol. 1, Issue 25, 12/18/96

** These drug names are included on the JCAHO's list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jcaho.org for more information about this JCAHO requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters wishes as to the level of detail included in publication.

Institute for Safe Medication Practices

www.ismp.org

Institute for Safe Medication Practices

ISMPs List of Confused Drug Names

Drug Name saquinavir (free base) saquinavir mesylate saquinavir SARAFEM SEROPHENE SEROQUEL** sertraline SERZONE** SINEQUAN SOLU-MEDROL SORIATANE SPIRIVA sufentanil** sumatriptan TAXOL** TAXOL TAXOTERE** TEGRETOL TEGRETOL TEGRETOL XR TEQUIN TEQUIN TESTODERM TESTODERM TTS TESTODERM W/ ADHESIVE tetanus diptheria toxoid (Td) tiagabine** TIAZAC TICLID tizanidine** TNKase TNKase TOBRADEX TOBREX TOPAMAX TOPROL XL TORADOL t-PA TRACLEER tramadol hydrochloride trazodone hydrochloride tretinoin TRICOR tuberculin purified protein derivative (PPD) tuberculin purified protein derivative (PPD) TYLENOL Confused Drug Name saquinavir mesylate saquinavir (free base) SINEQUAN SEROPHENE SARAFEM SERZONE** SORIATANE SEROQUEL** saquinavir DEPO-MEDROL sertraline INSPRA fentanyl** zolmitriptan TAXOTERE** PAXIL TAXOL** TEQUIN TEGRETOL XR TEGRETOL TEGRETOL TICLID TESTODERM W/ ADHESIVE TESTODERM TESTODERM TTS tuberculin purified protein derivative (PPD) tizanidine** ZIAC TEQUIN tiagabine** ACTIVASE t-PA TOBREX TOBRADEX TOPROL XL TOPAMAX FORADIL TNKase TRICOR trazodone hydrochloride tramadol hydrochloride isotretinoin TRACLEER influenza virus vaccine tetanus diptheria toxoid (Td) TYLENOL PM

Updated 4/1/05 ISMP 2005

ISMP Medication Safety Alert! Acute Care Edition Vol. 3, Issue 13, 7/1/98 Vol. 3, Issue 13, 7/1/98 Special Alert, 4/11/96 Vol. 6, Issue 18, 9/5/01 Vol. 6, Issue 18, 9/5/01 Vol. 7, Issue 11, 5/29/02 Vol. 8, Issue 16, 8/7/03 Vol. 7, Issue 11, 5/29/02 Special Alert, 4/11/96 Vol. 8, Issue 11, 5/29/03 Vol. 8, Issue 16, 8/7/03 Vol. 10, Issue 4, 2/24/05 Vol. 5, Issue 7, 4/5/00 Vol. 3, Issue 4, 2/25/98 Vol. 6, Issue 3, 2/7/01 Vol. 2, Issue 1, 1/15/97 Vol. 6, Issue 3, 2/7/01 Vol. 5, Issue 15, 7/26/00 Vol. 1, Issue 21, 10/23/96 Vol. 1, Issue 21, 10/23/96 Vol. 5, Issue 15, 7/26/00 Vol. 7, Issue 4, 2/20/02 Vol. 3, Issue 14, 4/8/98 Vol. 3, Issue 14, 4/8/98 Vol. 3, Issue 14, 4/8/98 Vol. 9, Issue 16, 8/12/04 Vol.8 , Issue 3, 2/6/03 Vol. 1, Issue 6, 3/27/96 Vol. 7, Issue 4, 2/20/02 Vol.8 , Issue 3, 2/6/03 Vol. 8, Issue 11, 5/29/03 Vol. 8, Issue 11, 5/29/03 Vol. 4, Issue 13, 6/30/99 Vol. 4, Issue 13, 6/30/99 Vol. 7, Issue 16, 8/7/02 Vol. 7, Issue 16, 8/7/02 Vol. 7, Issue 12, 6/12/02 Vol. 8, Issue 11, 5/29/03 Vol. 8, Issue 13, 6/26/03 Vol. 7, Issue 19, 9/18/02 Vol. 7, Issue 19, 9/18/02 Vol. 1, Issue 22, 11/6/96 Vol. 8, Issue 13, 6/26/03 Vol. 9, Issue 22, 11/4/04 Vol. 9, Issue 16, 8/12/04 Vol. 8, Issue 8, 4/17/03

** These drug names are included on the JCAHO's list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jcaho.org for more information about this JCAHO requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters wishes as to the level of detail included in publication.

Institute for Safe Medication Practices

www.ismp.org

Institute for Safe Medication Practices

ISMPs List of Confused Drug Names

Drug Name TYLENOL PM ULTRACET valacyclovir VALCYTE valganciclovir VALTREX VARIVAX VEXOL VIAGRA vinblastine** vincristine** VIOKASE VIOKASE 8 VIOXX VIRACEPT VIRAMUNE VOSOL VZIG WELLBUTRIN SR** WELLBUTRIN XL** XELODA XENICAL ZANTAC** ZEBETA ZEBETA ZESTRIL ZETIA ZETIA ZIAC ZOCOR zolmitriptan ZOSTRIX ZOVIRAX ZOVIRAX ZYBAN ZYPREXA** ZYPREXA ZYRTEC** ZYRTEC** ZYRTEC ZYVOX ZYVOX Confused Drug Name TYLENOL DURICEF valganciclovir VALTREX valacyclovir VALCYTE VZIG VOSOL ALLEGRA vincristine** vinblastine** VIOKASE 8 VIOKASE ZYVOX VIRAMUNE VIRACEPT VEXOL VARIVAX WELLBUTRIN XL** WELLBUTRIN SR** XENICAL XELODA ZYRTEC** DIABETA ZETIA ZETIA ZEBETA ZESTRIL TIAZAC COZAAR sumatriptan ZOVIRAX ZYVOX ZOSTRIX DIOVAN ZYRTEC** CELEXA ZYPREXA** ZANTAC** LIPITOR VIOXX ZOVIRAX

Updated 4/1/05 ISMP 2005

ISMP Medication Safety Alert! Acute Care Edition Vol. 8, Issue 8, 4/17/03 Vol. 7, Issue 6, 3/20/02 Vol. 7, Issue 13, 6/26/02 Vol. 7, Issue 13, 6/26/02 Vol. 7, Issue 13, 6/26/02 Vol. 7, Issue 13, 6/26/02 Vol.8 , Issue 2, 1/23/03 Vol. 1, Issue 11, 6/5/96 Vol. 3, Issue 12, 6/17/98 Vol. 5, Issue 10, 5/17/00 Vol. 5, Issue 10, 5/17/00 Vol. 7, Issue 6, 3/20/02 Vol. 7, Issue 6, 3/20/02 Vol. 7, Issue 17, 8/21/02 Vol. 7, Issue 17, 8/21/02 Vol. 7, Issue 17, 8/21/02 Vol. 1, Issue 11, 6/5/96 Vol.8 , Issue 2, 1/23/03 Vol. 9, Issue 1, 1/15/04 Vol. 9, Issue 1, 1/15/04 Vol. 4, Issue 18, 9/8/99 Vol. 4, Issue 18, 9/8/99 Vol. 5, Issue 22, 11/1/00 Vol. 5, Issue 18, 9/6/00 Vol. 8, Issue 11, 5/29/03 Vol.8 , Issue 6, 3/20/03 Vol. 8, Issue 11, 5/29/03 Vol.8 , Issue 6, 3/20/03 Vol. 1, Issue 6, 3/27/96 Vol. 1, Issue 1, 1/15/96 Vol. 3, Issue 4, 2/25/98 Vol. 8, Issue 21, 10/16/03 Vol. 7, Issue 17, 8/21/02 Vol. 8, Issue 21, 10/16/03 Vol. 2, Issue 19, 9/24/97 Vol. 6, Issue 22, 10/31/01 Vol. 3, Issue 18, 9/9/98 Vol. 6, Issue 22, 10/31/01 Vol. 5, Issue 22, 11/1/00 Vol. 8, Issue 7, 4/4/03 Vol. 7, Issue 17, 8/21/02 Vol. 7, Issue 17, 8/21/02

** These drug names are included on the JCAHO's list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jcaho.org for more information about this JCAHO requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters wishes as to the level of detail included in publication.

Institute for Safe Medication Practices

www.ismp.org