Institute for Safe Medication Practices

1
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),
providing legal protection and confidentiality for patient safety data and error reports it receives.
* These drug names are included on The Joint Commissions list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Institute for Safe
Medication Practices
www.ismp.org
ISMPs List of Confused Drug Names
his list of confused drug names, which includes look-alike and
sound-alike name pairs, consists of those name pairs that have
been involved in medication errors published in the ISMP
Medication Safety Alert!

and the ISMP Medication Safety Alert!

Community/Ambulatory Care Edition. The errors involving these

medications were reported to ISMP through the ISMP Medication
Errors Reporting Program (MERP).
This list also contains the names that appear on The Joint
Commissions list of look-alike and sound-alike names. The Joint
Commission established a National Patient Safety Goal that requires
each accredited organization to identify a list of look-alike or sound-
alike drugs used in the organization. Those names that appear on The
Joint Commissions list have been noted with an asterisk (*) below.
T
Drug Name Confused Drug Name
amLODIPine aMILoride
amphotericin B* Abelcet*
amphotericin B* Ambisome*
Anacin Anacin-3
Anacin-3 Anacin
antacid Atacand
Antivert Axert
Anzemet Avandamet
Apresoline Priscoline
argatroban Aggrastat
argatroban Orgaran
Aricept Aciphex
Aricept Azilect
aripiprazole proton pump inhibitors
aripiprazole rabeprazole
Asacol Os-Cal
Atacand antacid
Atrovent Natru-Vent
Avandamet Anzemet
Avandia Prandin
Avandia* Coumadin*
AVINza INVanz
AVINza* Evista*
Axert Antivert
azaCITIDine azaTHIOprine
azaTHIOprine azaCITIDine
Azilect Aricept
B & O (belladonna and opium) Beano
BabyBIG HBIG (hepatitis B immune globulin)
Bayhep-B Bayrab
Bayhep-B Bayrho-D
Bayrab Bayhep-B
Bayrab Bayrho-D
Bayrho-D Bayhep-B
Bayrho-D Bayrab

I
S
M
P
2
0
1
0
Drug Name Confused Drug Name
Abelcet* amphotericin B*
Accupril Aciphex
acetaZOLAMIDE* acetoHEXAMIDE*
acetic acid for irrigation glacial acetic acid
acetoHEXAMIDE* acetaZOLAMIDE*
Aciphex Accupril
Aciphex Aricept
Activase Cathflo Activase
Activase TNKase
Actonel Actos
Actos Actonel
Adacel (Tdap) Daptacel (DTaP)
Adderall Inderal
Adderall Adderall XR
Adderall XR Adderall
Advair* Advicor*
Advicor* Advair*
Advicor Altocor
Afrin (oxymetazoline) Afrin (saline)
Afrin (saline) Afrin (oxymetazoline)
Aggrastat argatroban
Aldara Alora
Alkeran Leukeran
Alkeran Myleran
Allegra Viagra
Alora Aldara
ALPRAZolam* LORazepam*
Altocor Advicor
amantadine amiodarone
Amaryl Reminyl
Ambisome* amphotericin B*
Amicar* Omacor*
Amikin Kineret
aMILoride amLODIPine
amiodarone amantadine
Institute for Safe Medication Practices
2
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),
providing legal protection and confidentiality for patient safety data and error reports it receives.
* These drug names are included on The Joint Commissions list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Institute for Safe
Medication Practices
www.ismp.org
Drug Name Confused Drug Name
Clindesse Clindets
Clindets Clindesse
clomiPHENE clomiPRAMINE
clomiPRAMINE clomiPHENE
clonazePAM cloNIDine
clonazePAM LORazepam
cloNIDine clonazePAM
cloNIDine* KlonoPIN*
Clozaril Colazal
Coagulation factor IX (recombinant) Factor IX Complex, Vapor Heated
codeine Lodine
Colace Cozaar
Colazal Clozaril
colchicine Cortrosyn
Comvax Recombivax HB
Cortrosyn colchicine
Coumadin* Avandia*
Coumadin* Cardura*
Cozaar Colace
Cozaar Zocor
cycloSERINE cycloSPORINE
cycloSPORINE cycloSERINE
Cymbalta Symbyax
DACTINomycin DAPTOmycin
Daptacel (DTaP) Adacel (Tdap)
DAPTOmycin DACTINomycin
Darvocet* Percocet*
Darvon Diovan
DAUNOrubicin* DAUNOrubicin citrate liposomal*
DAUNOrubicin* DOXOrubicin*
DAUNOrubicin* IDArubicin*
DAUNOrubicin citrate liposomal* DAUNOrubicin*
Denavir indinavir
Depakote Depakote ER
Depakote ER Depakote
Depo-Medrol Solu-MEDROL
Depo-Provera Depo-subQ provera 104
Depo-subQ provera 104 Depo-Provera
desipramine disopyramide
dexmethylphenidate methadone
Diabenese Diamox
Diabeta* Zebeta*
Diamox Diabenese
Diflucan* Diprivan*
Dilacor XR Pilocar
Dilaudid Dilaudid-5

I
S
M
P
2
0
1
0
ISMPs List of Confused Drug Names
Drug Name Confused Drug Name
Beano B & O (belladonna and opium)
Benadryl benazepril
benazepril Benadryl
Benicar Mevacor
Betadine (with providone-iodine) Betadine (without providone-iodine)
Betadine (without providone-iodine) Betadine (with providone-iodine)
Bextra Zetia
Bicillin C-R Bicillin L-A
Bicillin L-A Bicillin C-R
Bicitra Polycitra
Brethine Methergine
Brevibloc Brevital
Brevital Brevibloc
buPROPion busPIRone
busPIRone buPROPion
Capadex [non-US product] Kapidex
Capex Kapidex
Carac Kuric
captopril carvedilol
carBAMazepine OXcarbazepine
CARBOplatin CISplatin
Cardura* Coumadin*
carvedilol captopril
Casodex Kapidex
Cathflo Activase Activase
Cedax Cidex
ceFAZolin cefTRIAXone
cefTRIAXone ceFAZolin
CeleBREX* CeleXA*
CeleBREX* Cerebyx*
CeleXA ZyPREXA
CeleXA* CeleBREX*
CeleXA* Cerebyx*
Cerebyx* CeleBREX*
Cerebyx* CeleXA*
cetirizine sertraline
chlordiazePOXIDE chlorproMAZINE
chlorproMAZINE chlordiazePOXIDE
chlorproMAZINE chlorproPAMIDE
chlorproPAMIDE chlorproMAZINE
Cidex Cedax
CISplatin CARBOplatin
Claritin (loratadine) Claritin Eye (ketotifen fumarate)
Claritin-D Claritin-D 24
Claritin-D 24 Claritin-D
Claritin Eye (ketotifen fumarate) Claritin (loratadine)
Institute for Safe Medication Practices
3
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),
providing legal protection and confidentiality for patient safety data and error reports it receives.
* These drug names are included on The Joint Commissions list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Institute for Safe
Medication Practices
www.ismp.org

I
S
M
P
2
0
1
0
ISMPs List of Confused Drug Names
Drug Name Confused Drug Name
Fiorinal Fioricet
flavoxate fluvoxamine
Flonase Flovent
Flovent Flonase
flumazenil influenza virus vaccine
FLUoxetine PARoxetine
FLUoxetine DULoxetine
fluvoxamine flavoxate
Folex Foltx
folic acid* folinic acid (leucovorin calcium)*
folinic acid (leucovorin calcium)* folic acid*
Foltx Folex
fomepizole omeprazole
Foradil Fortical
Foradil Toradol
Fortical Foradil
gentamicin gentian violet
gentian violet gentamicin
glacial acetic acid acetic acid for irrigation
glipiZIDE glyBURIDE
glyBURIDE glipiZIDE
Granulex Regranex
guaiFENesin guanFACINE
guanFACINE guaiFENesin
HBIG (hepatitis B immune globulin) BabyBIG
Healon Hyalgan
heparin* Hespan*
Hespan* heparin*
HMG-CoA Reductase Inhibitors ("statins") nystatin
HumaLOG* HumuLIN*
HumaLOG* NovoLOG*
HumaLOG Mix 75/25 HumuLIN 70/30
Humapen Memoir (for use with HumaLOG) Humira Pen
Humira Pen Humapen Memoir (for use with HumaLOG)
HumuLIN* NovoLIN*
HumuLIN* HumaLOG*
HumuLIN 70/30 HumaLOG Mix 75/25
Hyalgan Healon
hydrALAZINE* hydrOXYzine*
HYDROcodone* oxyCODONE*
Hydrogesic hydrOXYzine
HYDROmorphone* morphine*
hydrOXYzine Hydrogesic
hydrOXYzine* hydrALAZINE*
IDArubicin* DAUNOrubicin*
IDArubicin* DOXOrubicin*
Drug Name Confused Drug Name
Dilaudid-5 Dilaudid
dimenhyDRINATE diphenhydrAMINE
diphenhydrAMINE dimenhyDRINATE
Dioval Diovan
Diovan Dioval
Diovan Zyban
Diovan Darvon
Diprivan* Diflucan*
Diprivan Ditropan
disopyramide desipramine
Ditropan Diprivan
DOBUTamine DOPamine
DOPamine DOBUTamine
Doxil Paxil
DOXOrubicin* DAUNOrubicin*
DOXOrubicin* DOXOrubicin liposomal*
DOXOrubicin* IDArubicin*
DOXOrubicin liposomal* DOXOrubicin*
Dulcolax (bisacodyl) Dulcolax (docusate sodium)
Dulcolax (docusate sodium) Dulcolax (bisacodyl)
DULoxetine FLUoxetine
Durasal Durezol
Durezol Durasal
Duricef Ultracet
Dynacin Dynacirc
Dynacirc Dynacin
edetate calcium disodium edetate disodium
edetate disodium edetate calcium disodium
Effexor* Effexor XR*
Effexor XR* Effexor*
Enbrel Levbid
Engerix-B adult Engerix-B pediatric/adolescent
Engerix-B pediatric/adolescent Engerix-B adult
Enjuvia Januvia
ePHEDrine* EPINEPHrine*
EPINEPHrine* ePHEDrine*
Estratest Estratest HS
Estratest HS Estratest
ethambutol Ethmozine
Ethmozine ethambutol
Evista* AVINza*
Factor IX Complex, Vapor Heated Coagulation factor IX (recombinant)
Femara Femhrt
Femhrt Femara
fentaNYL SUFentanil
Fioricet Fiorinal
Institute for Safe Medication Practices
4
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),
providing legal protection and confidentiality for patient safety data and error reports it receives.
* These drug names are included on The Joint Commissions list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Institute for Safe
Medication Practices
www.ismp.org

I
S
M
P
2
0
1
0
ISMPs List of Confused Drug Names
Drug Name Confused Drug Name
Lariam Levaquin
Lasix Luvox
Lente Lantus
leucovorin calcium* Leukeran*
Leukeran Alkeran
Leukeran Myleran
Leukeran* leucovorin calcium*
Levaquin Lariam
Levbid Enbrel
levetiracetam levofloxacin
levofloxacin levetiracetam
levothyroxine lamoTRIgine
levothyroxine Lanoxin
Lexapro Loxitane
Lipitor Loniten
Lipitor ZyrTEC
lithium carbonate lanthanum carbonate
Lodine codeine
Lodine iodine
Loniten Lipitor
Lopressor Lyrica
LORazepam* ALPRAZolam*
LORazepam clonazePAM
LORazepam Lovaza
Lotronex Protonix
Lovaza LORazepam
Loxitane Lexapro
Loxitane Soriatane
Lunesta Neulasta
Lupron Depot-3 Month Lupron Depot-Ped
Lupron Depot-Ped Lupron Depot-3 Month
Luvox Lasix
Lyrica Lopressor
Maalox Maalox Total Stomach Relief
Maalox Total Stomach Relief Maalox
Matulane Materna
Materna Matulane
Maxzide Microzide
Menactra Menomune
Menomune Menactra
Mephyton methadone
Metadate methadone
Metadate CD Metadate ER
Metadate ER Metadate CD
Metadate ER methadone
metFORMIN* metroNIDAZOLE*
Drug Name Confused Drug Name
Inderal Adderall
indinavir Denavir
inFLIXimab riTUXimab
influenza virus vaccine flumazenil
influenza virus vaccine tuberculin purified protein derivative (PPD)
Inspra Spiriva
INVanz AVINza
iodine Lodine
Isordil Plendil
isotretinoin tretinoin
Jantoven Janumet
Jantoven Januvia
Janumet Jantoven
Janumet Januvia
Janumet Sinemet
Januvia Enjuvia
Januvia Jantoven
Januvia Janumet
K-Phos Neutral Neutra-Phos-K
Kaopectate (bismuth subsalcylate) Kaopectate (docusate calcium)
Kaopectate (docusate calcium) Kaopectate (bismuth subsalcylate)
Kadian Kapidex
Kaletra Keppra
Kapidex Capadex [non-US product]
Kapidex Capex
Kapidex Casodex
Kapidex Kadian
Keflex Keppra
Keppra Kaletra
Keppra Keflex
Ketalar ketorolac
ketorolac Ketalar
ketorolac methadone
Kineret Amikin
KlonoPIN* cloNIDine *
Kuric Carac
Kwell Qwell
LaMICtal LamISIL
LamISIL LaMICtal
lamiVUDine* lamoTRIgine*
lamoTRIgine* lamiVUDine*
lamoTRIgine levothyroxine
Lanoxin levothyroxine
Lanoxin naloxone
lanthanum carbonate lithium carbonate
Lantus Lente
Institute for Safe Medication Practices
5
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),
providing legal protection and confidentiality for patient safety data and error reports it receives.
* These drug names are included on The Joint Commissions list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Institute for Safe
Medication Practices
www.ismp.org
ISMPs List of Confused Drug Names
Drug Name Confused Drug Name
methadone dexmethylphenidate
methadone ketorolac
methadone Mephyton
methadone Metadate
methadone Metadate ER
methadone methylphenidate
Methergine Brethine
methimazole metolazone
methylphenidate methadone
metolazone methimazole
metoprolol succinate metoprolol tartrate
metoprolol tartrate metoprolol succinate
metroNIDAZOLE* metFORMIN*
Mevacor Benicar
Micronase Microzide
Microzide Maxzide
Microzide Micronase
midodrine Midrin
Midrin midodrine
mifepristone misoprostol
Miralax Mirapex
Mirapex Miralax
misoprostol mifepristone
morphine* HYDROmorphone*
morphine - non-concentrated oral liquid* morphine - oral liquid concentrate*
morphine - oral liquid concentrate* morphine - non-concentrated oral liquid*
Motrin Neurontin
MS Contin* OxyCONTIN*
Mucinex* Mucomyst*
Mucinex D Mucinex DM
Mucinex DM Mucinex D
Mucomyst* Mucinex*
Myleran Alkeran
Myleran Leukeran
naloxone Lanoxin
Narcan Norcuron
Natru-Vent Atrovent
Navane Norvasc
Neo-Synephrine (oxymetazoline) Neo-Synephrine (phenylephrine)
Neo-Synephrine (phenylephrine) Neo-Synephrine (oxymetazoline)
Neulasta Lunesta
Neulasta Neumega
Neumega Neupogen
Neumega Neulasta
Neupogen Neumega
Neurontin Motrin
Drug Name Confused Drug Name
Neurontin Noroxin
Neutra-Phos-K K-Phos Neutral
NexAVAR NexIUM
NexIUM NexAVAR
niCARdipine NIFEdipine
NIFEdipine niCARdipine
NIFEdipine niMODipine
niMODipine NIFEdipine
Norcuron Narcan
Normodyne Norpramin
Noroxin Neurontin
Norpramin Normodyne
Norvasc Navane
NovoLIN* HumuLIN*
NovoLIN* NovoLOG*
NovoLIN 70/30* NovoLOG Mix 70/30*
NovoLOG* HumaLOG*
NovoLOG* NovoLIN*
NovoLOG FLEXPEN NovoLOG Mix 70/30 FLEXPEN
NovoLOG Mix 70/30 FLEXPEN NovoLOG FLEXPEN
NovoLOG Mix 70/30* NovoLIN 70/30*
nystatin HMG-CoA Reductase Inhibitors ("statins")
Occlusal-HP Ocuflox
Ocuflox Occlusal-HP
OLANZapine QUEtiapine
Omacor* Amicar*
omeprazole fomepizole
opium tincture* paregoric (camphorated tincture of opium)*
Oracea Orencia
Orencia Oracea
Orgaran argatroban
Ortho Tri-Cyclen Ortho Tri-Cyclen LO
Ortho Tri-Cyclen LO Ortho Tri-Cyclen
Os-Cal Asacol
OXcarbazepine carBAMazepine
oxyCODONE* HYDROcodone*
oxyCODONE* OxyCONTIN*
OxyCONTIN* MS Contin*
OxyCONTIN* oxyCODONE*
paclitaxel paclitaxel protein-bound particles
paclitaxel protein-bound particles paclitaxel
Pamelor Panlor DC
Pamelor Tambocor
Panlor DC Pamelor
paregoric (camphorated tincture of opium)* opium tincture*
PARoxetine FLUoxetine

I
S
M
P
2
0
1
0
Institute for Safe Medication Practices
6
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),
providing legal protection and confidentiality for patient safety data and error reports it receives.
* These drug names are included on The Joint Commissions list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement..
Institute for Safe
Medication Practices
www.ismp.org
ISMPs List of Confused Drug Names
Drug Name Confused Drug Name
Patanol Platinol
Pavulon Peptavlon
Paxil Doxil
Paxil Taxol
Paxil Plavix
pemetrexed pralatrexate
Peptavlon Pavulon
Percocet* Darvocet*
Percocet Procet
PENTobarbital PHENobarbital
PHENobarbital PENTobarbital
Pilocar Dilacor XR
Platinol Patanol
Plavix Paxil
Plendil Isordil
pneumococcal 7-valent vaccine pneumococcal polyvalent vaccine
pneumococcal polyvalent vaccine pneumococcal 7-valent vaccine
Polycitra Bicitra
pralatrexate pemetrexed
Prandin Avandia
Precare Precose
Precose Precare
prednisoLONE predniSONE
predniSONE prednisoLONE
PriLOSEC* PROzac*
Priscoline Apresoline
probenecid Procanbid
Procan SR Procanbid
Procanbid probenecid
Procanbid Procan SR
Procardia XL Protain XL
Procet Percocet
Prograf PROzac
propylthiouracil Purinethol
Proscar Provera
Protain XL Procardia XL
protamine Protonix
proton pump inhibitors aripiprazole
Protonix Lotronex
Protonix protamine
Provera Proscar
Provera PROzac
PROzac Prograf
PROzac* PriLOSEC*
PROzac Provera
Purinethol propylthiouracil
Drug Name Confused Drug Name
QUEtiapine OLANZapine
quiNIDine quiNINE
quiNINE quiNIDine
Qwell Kwell
rabeprazole aripiprazole
Razadyne Rozerem
Recombivax HB Comvax
Regranex Granulex
Reminyl Robinul
Reminyl Amaryl
Renagel Renvela
Renvela Renagel
Reprexain ZyPREXA
Restoril Risperdal
Retrovir* ritonavir*
Rifadin Rifater
Rifamate rifampin
rifampin Rifamate
rifampin rifaximin
Rifater Rifadin
rifaximin rifampin
Risperdal Restoril
risperidone ropinirole
Ritalin ritodrine
Ritalin LA Ritalin SR
Ritalin SR Ritalin LA
ritodrine Ritalin
ritonavir* Retrovir*
riTUXimab inFLIXimab
Robinul Reminyl
ropinirole risperidone
Roxanol Roxicodone Intensol
Roxanol Roxicet
Roxicet Roxanol
Roxicodone Intensol Roxanol
Rozerem Razadyne
Salagen selegiline
SandIMMUNE SandoSTATIN
SandoSTATIN SandIMMUNE
saquinavir SINEquan
saquinavir (free base) saquinavir mesylate
saquinavir mesylate saquinavir (free base)
Sarafem Serophene
selegiline Salagen
Serophene Sarafem
SEROquel SEROquel XR

I
S
M
P
2
0
1
0
7
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),
providing legal protection and confidentiality for patient safety data and error reports it receives.
* These drug names are included on The Joint Commissions list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.
ISMPs List of Confused Drug Names
Drug Name Confused Drug Name
SEROquel Serzone
SEROquel SINEquan
SEROquel XR SEROquel
sertraline cetirizine
sertraline Soriatane
Serzone SEROquel
Sinemet Janumet
SINEquan saquinavir
SINEquan SEROquel
SINEquan Singulair
SINEquan Zonegran
Singulair SINEquan
sitaGLIPtin SUMAtriptan
Solu-CORTEF Solu-MEDROL
Solu-MEDROL Depo-Medrol
Solu-MEDROL Solu-CORTEF
Sonata Soriatane
Soriatane Loxitane
Soriatane sertraline
Soriatane Sonata
sotalol Sudafed
Spiriva Inspra
Sudafed sotalol
Sudafed Sudafed PE
Sudafed PE Sudafed
SUFentanil fentaNYL
sulfADIAZINE sulfiSOXAZOLE
sulfiSOXAZOLE sulfADIAZINE
SUMAtriptan sitaGLIPtin
SUMAtriptan zolmitriptan
Symbyax Cymbalta
Tambocor Pamelor
Taxol Taxotere
Taxol Paxil
Taxotere Taxol
TEGretol TEGretol XR
TEGretol Tequin
TEGretol TRENtal
TEGretol XR TEGretol
Tequin TEGretol
Tequin Ticlid
Testoderm TTS Testoderm
Testoderm TTS Testoderm with Adhesive
Testoderm with Adhesive Testoderm
Testoderm with Adhesive Testoderm TTS
Testoderm Testoderm TTS
Drug Name Confused Drug Name
Testoderm Testoderm with Adhesive
tetanus diptheria toxoid (Td) tuberculin purified protein derivative (PPD)
Thalomid Thiamine
Thiamine Thalomid
tiaGABine* tiZANidine*
Tiazac Ziac
Ticlid Tequin
tiZANidine* tiaGABine*
TNKase Activase
TNKase t-PA
Tobradex Tobrex
Tobrex Tobradex
TOLAZamide TOLBUTamide
TOLBUTamide TOLAZamide
Topamax* Toprol-XL*
Toprol-XL* Topamax*
Toradol Foradil
t-PA TNKase
Tracleer Tricor
traMADol* traZODone*
traZODone* traMADol*
TRENtal TEGretol
tretinoin isotretinoin
Tricor Tracleer
tromethamine Trophamine
Trophamine tromethamine
tuberculin purified protein derivative (PPD) influenza virus vaccine
tuberculin purified protein derivative (PPD) tetanus diptheria toxoid (Td)
Tylenol Tylenol PM
Tylenol PM Tylenol
Ultracet Duricef
valacyclovir valganciclovir
Valcyte Valtrex
valganciclovir valacyclovir
Valtrex Valcyte
Varivax VZIG (varicella-zoster immuneglobulin)
Vesanoid Vesicare
Vesicare Vesanoid
Vexol Vosol
Viagra Allegra
vinBLAStine* vinCRIStine*
vinCRIStine* vinBLAStine*
Viokase Viokase 8
Viokase 8 Viokase
Vioxx Zyvox
Viracept Viramune

I
S
M
P
2
0
1
0
Institute for Safe Medication Practices
Institute for Safe
Medication Practices
www.ismp.org
Institute for Safe Medication Practices
8
Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at
www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),
providing legal protection and confidentiality for patient safety data and error reports it receives.
* These drug names are included on the The Joint Commissions list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements
of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Institute for Safe
Medication Practices
www.ismp.org
ISMPs List of Confused Drug Names
Drug Name Confused Drug Name
Viramune Viracept
Vosol Vexol
VZIG (varicella-zoster immuneglobulin) Varivax
Wellbutrin SR* Wellbutrin XL*
Wellbutrin XL* Wellbutrin SR*
Xanax* Zantac*
Xeloda Xenical
Xenical Xeloda
Yasmin Yaz
Yaz Yasmin
Zantac* Xanax*
Zantac* ZyrTEC*
Zebeta* Diabeta*
Zebeta Zetia
Zegerid Zestril
Zelapar (Zydis formulation) ZyPREXA Zydis
Zestril Zegerid
Zestril* Zetia*
Zestril* ZyPREXA*
Zetia Bextra
Zetia Zebeta
Zetia* Zestril*
Ziac Tiazac
Drug Name Confused Drug Name
Zocor Cozaar
Zocor* ZyrTEC*
zolmitriptan SUMAtriptan
Zonegran SINEquan
Zostrix Zovirax
Zovirax Zyvox
Zovirax Zostrix
Zyban Diovan
ZyPREXA CeleXA
ZyPREXA Reprexain
ZyPREXA* Zestril*
ZyPREXA* ZyrTEC*
ZyPREXA Zydis Zelapar (Zydis formulation)
ZyrTEC Lipitor
ZyrTEC* Zantac*
ZyrTEC* Zocor*
ZyrTEC* ZyPREXA*
ZyrTEC ZyrTEC-D
ZyrTEC (cetirizine) ZyrTEC Itchey Eye Drops (ketotifen fumarate)
ZyrTEC-D ZyrTEC
ZyrTEC Itchey Eye Drops (ketotifen fumarate) ZyrTEC (cetirizine)
Zyvox Vioxx
Zyvox Zovirax

I
S
M
P
2
0
1
0