Sound-Alike, Look-Alike Drugs (SALAD) have recently floated to the top of my attention with the release of the Institute for Safe Medication Practices (ISMP) recommended list of Tall Man Letters for look-alike drugs. I mentioned the new list on Twitter which resulted in a short, but interesting conversation with some colleagues.
SALADs have been problematic for quite some time and many solutions have been proposed, including Tall Man Lettering, physical separation of look-alike drugs, printing of both brand and generic names on packaging and storage bins, use of colorful warning labels, and so on and so forth. The problem with all these solutions is human involvement. Working in acute care pharmacy has taught me over and over again that all the above systems may decrease error, but certainly don’t eliminate them.
One classic example of a SALAD combination is hydroxyzine and hydralazine; similar names, but completely different uses. These two medications have been mixed up and dispensed one in place of the other in every single acute care facility I’ve worked in. And yes, in some cases the wrong drug made it all the way to the patient.
In the FDA-Approved list of generic drug names with Tall Man Letters, the two drugs are represented as follows:
hydrOXYzine – hydrALAZINE
Other possible solutions include:
I realize the differences are subtle, but I actually prefer the lowercase first letter with capitalized letters in the middle of the name. Ask other pharmacists and you’ll probably get different answers. One of the most complete lists of Tall Man Letter medications I have ever seen can be found at the Clinical Architecture website. If you’ve never been to the Clinical Architecture website, then I suggest you pay it a visit and spend some time digging around.
Besides the use of Tall Man Lettering, physical separation, etc, technology can help pharmacies deal with sound-alike, look-alike drugs. Both automated carousel technology and robotics can help manage physical separation of the medications and eliminate visual bias generated by human eyes. And when properly implemented and utilized, bar-coding technology can certainly aid in identifying medications correctly. Bar-codes don’t care when medications have similar names.
In the case of sound-alike, look-alike medications it shouldn’t be a one-or-the-other approach. Rather it should be an all-hands-on-deck approach.