Sound-Alike Medication Alerts

The Institute for Safe Medication Practices released a safety alert in the August 2008 Nurse Advise-ERR regarding medication errors seen with two pairs of sound-alike medications. One pair includes the antineoplastic agent sorafenib (Nexavar) and the gastrointestinal agent esomeprazole (Nexium). The other pair includes two antidepressants: fluvoxamine (Luvox) and fluoxetine (Prozac, Sarafem).

Sorafenib, available as a 400 mg tablet dosed twice daily, is used to inhibit tumor growth in advanced renal cell carcinoma; esomeprazole, available in 20 mg and 40 mg capsules, is administered once daily for gastroesophageal reflux disease, duodenal ulcers, and treatment of Helicobacter pylori infection. Knowing the indication for the drug can often provide a clue to identify errors for some sound-alike drug pairs.

This is not the case for the second sound-alike pair because fluvoxamine and fluoxetine not only have similar names but they are both used to treat many of the same psychiatric and behavioral disorders, including major depression and obsessive-compulsive disorder. Even though the two drugs are both selective serotonin reuptake inhibitors, they are available at widely varying dosages that can further compound the potential for adverse outcomes. Fluvoxamine 25 mg, 50 mg, and 100 mg tablets are available for once or twice daily dosing up to a maximum of 300 mg daily. Available in 10 mg, 20 mg, and 40 mg immediate release capsules, 90 mg delayed-release capsules, 10 mg tablets, and as an oral solution of 20 mg/5 ml, fluoxetine is typically dosed once daily at 20 mg, or as a divided dose up to 80 mg daily. The 90 mg delayed-release capsule is given only as a once-weekly dose.

Because of the potential for drug errors with these sound-alike medications, providers should maintain a high index of suspicion when they are ordered and administered. Pay special attention to the dosing strength and frequency. Sound-alike drug errors often contain dosages that appear to be outside the normal dosing regimen or require numerous pills or pill splitting to administer a dose. Don’t rely on visual inspection either because pills may vary among manufacturers. More than a dozen generic companies distribute Fluoxetine, for example, which impacts the size, shape, and color of the medications. For drugs that are easily confused, it may also be helpful to identify them by both their generic and trade names and to flag high-alert medications with warning messages.

The medication reconciliation process is a crucial step that allows nurses to double check for appropriate dosing. It should include verification of the drug name, strength, and indication.

atinurse, Thank you for following and posting your comments on the forum . Teresa

I really hope this helps you and others...  Teresa