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Umesh Modi is a chartered accountant, and Pamini Jatheeskumar is a chartered certified accountant at Silver Levene...
  Don Lavoie is alcohol programme manager at Public Health England and Gul Root is lead...
Don Lavoie is alcohol programme manager at Public Health England and Gul Root is lead pharmacist, Health and Wellbeing Directorate, Public Health England
More inWhite Papers  

a alert imageJanuary 11 2018

Healthcare professionals are being asked to be extra vigilant when dispensing or prescribing medicines with commonly confused drug names.

The MHRA’s latest Drug Safety Update gives a list of common errors of names that sound alike or look alike:

clobazam (benzodiazepine)

clonazepam (antiepileptic drug)

atenolol (beta blocker)

amlodipine (calcium channel blocker)

propranolol (beta blocker)

prednisolone (corticosteroid)

risperidone (antipsychotic)

ropinirole (dopamine agonist)

sulfadiazine (antibiotic)

sulfasalazine (disease-modifying anti-rheumatic drug)

amlodipine (indicated for hypertension and angina)         

nimodipine (indicated for the prevention of ischaemic neurological deficits following aneurysmal subarachnoid haemorrhage)

“We are aware of recent cases, including cases with fatal outcomes, in which patients have received the wrong medicine due to confusion between similarly named or sounding brand or generic names,” said the MHRA. “Since our last Drug Safety Update on drug-name confusion in 2013, we have received Yellow Card reports of harm following confusion between the drugs listed in the table.”

The MHRA says “if pharmacists have any doubt about which medicine is intended, contact the prescriber before dispensing the drug.” They should also “follow local and professional guidance in relation to checking the right medicine has been dispensed to a patient.”

Health professionals are asked to “report suspected adverse drug reactions where harm has occurred as a result of a medication error on a Yellow Card or via local risk management systems that feed into the National Reporting and Learning System.”

Links:
MHRA Drug Safety Update: monthly PDF newsletters        
MHRA Drug Safety Update: monthly PDF newsletter. January 6 2018. 11;6.                 
Drug name confusion DSU – January 2018              
Drug name confusion DSU – April 2013  

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