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U.S. Department of Health and Human Services

Drugs

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Drug Products Associated with Medication Errors

 

Drug Name

Reason

Anzemet

Dosing errors, labeling

Bentyl

Dosing errors, labeling

Bextra: Valdecoxib or bucindolol

Discontinued bucindolol phase III clinical trial, info comes up on internet search

Bumetanide and Norepinephrine

Vial labels and caps make the two bottles look very similar.

Durezol and Durasal

Similar-Sounding Drugs

Edetate Disodium (marketed as Endrate and generic products)

Patient given Edetate Disodium instead of Edetate Calcium Disodium (Calcium Disodium Versenate) or when Edetate Disodium was used for "chelation therapies"

Fleet Phospho-soda disclaimer icon

Dosing size

Flomax and Volmax

Look alike, sound alike Names

Foradil Aerolizer and Spiriva HandiHaler capsules

Misadministration

Insulin and Heparin

Similar-looking vials are often next to each other on a counter, a drug cart, or under a pharmacy IV admixture hood. Both drugs are dosed in units.

Kaeopectate

Reformulation, labeling

Kaletra (lopinavir/ritonavir) and Keppra (levetiracetam)

Similar-Named Drugs

Keppra/Kaletra

Sound alike names

Lanoxin/Levoxine disclaimer icon

Similar sounding, changed name to: Levoxyl

Maalox Total Relief and Maalox Liquid Products

Similar-Sounding Drugs

Methadone/methylphenidate (Metadate)

Dispensing error

Nimodipine oral capsules

Route of administration --  medication should never be given by intravenous administration

Opium tincture/paregoric

Drug names, DTO abbreviation

Reminyl and Amaryl

Similar-Named Drugs

respiridone (risperdal) and ropinirole (Requip)

Similarities of both the brand (proprietary) and generic (established) names and container/carton packaging.

Roxanol (morphine sulfate) Concentrated Oral Solution

Morphine oral solutions ordered in milligrams (mg) were mistakenly interchanged for milliliters (mL) of the product

Taxotere, Taxol disclaimer icon

Similar named drugs

Temodar

Dosage/label design

Transdermal patches

Patch design

Zantac and Zyrtec

Look alike, sound alike Names

 

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Related Information

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