ISMP Look-Alike Sound-Alike Drug Names 1 — Questions and Answers
Question 1: ISMP defines 'look-alike/sound-alike' (LASA) drug pairs as medications that:
- Have the same mechanism of action
- Have names or packaging that can be confused with one another (Correct answer)
- Are manufactured by the same company
- Treat the same disease
Correct answer: Have names or packaging that can be confused with one another
LASA drug pairs have names or appearances so similar that they can be confused during ordering, dispensing, or administration, leading to medication errors.
Question 2: Which ISMP-recommended strategy most directly prevents confusion between DOBUTamine and DOPamine?
- Store them in the same drawer
- Use tall man lettering to highlight the different portions of each name (Correct answer)
- Abbreviate both as 'D'
- Use verbal orders only
Correct answer: Use tall man lettering to highlight the different portions of each name
Tall man lettering (DOBUTamine vs DOPamine) capitalizes the unique letters in each name, making visual differentiation easier at a glance.
Question 3: ISMP recommends that LASA drug pairs stored in pharmacies be:
- Stored alphabetically next to each other
- Stored in separate locations with auxiliary warning labels (Correct answer)
- Stored unlabeled to reduce clutter
- Given identical packaging for consistency
Correct answer: Stored in separate locations with auxiliary warning labels
Separating LASA drugs in storage and adding auxiliary warning labels prevents accidental selection of the wrong drug during dispensing.
Question 4: Which pair is a classic ISMP LASA example involving look-alike packaging as well as name similarity?
- Aspirin and Tylenol
- Hydroxyzine and Hydralazine (Correct answer)
- Vitamin C and Vitamin D
- Saline and sterile water
Correct answer: Hydroxyzine and Hydralazine
Hydroxyzine (antihistamine/anxiolytic) and Hydralazine (antihypertensive) are a well-known LASA pair with similar names that have led to serious patient harm.
Question 5: Which technology does ISMP recommend to help pharmacists detect LASA errors during order processing?
- Manual paper logs
- Clinical decision support alerts in pharmacy information systems (Correct answer)
- Color-coded pill boxes
- Visual inspection only
Correct answer: Clinical decision support alerts in pharmacy information systems
Clinical decision support alerts in pharmacy systems flag potential LASA drug substitutions during order entry, prompting pharmacist verification.
Question 6: According to ISMP, a key strategy for reducing LASA errors at the nursing unit level is to:
- Remove all drug labels from packaging
- Include the drug indication on the medication administration record (Correct answer)
- Have nurses memorize all LASA pairs
- Use only verbal communication for drug names
Correct answer: Include the drug indication on the medication administration record
Including the clinical indication (e.g., 'for hypertension') on the MAR helps nurses question a drug that doesn't match the patient's known conditions, catching LASA errors.
