MHRA Warning – Watch out for look-alikes & sound-alikes

The MHRA have recently highlighted the dangers associated with medicines with look-alike or sound-alike names – including cases with fatal outcomes, in which patients received the wrong medicine due to confusion between similar names.

Drugs pairs known to have been linked to errors include: Clobazam / Clonazepam; Atenolol / Amlodipine; Propranolol / Prednisolone; Risperidone / Ropinirole; Sulfadiazine / Sulfasalazine and Amlodipine / Nimodipine.

The MHRA offer the following Advice for healthcare professionals:

  • be extra vigilant when prescribing and dispensing medicines with commonly confused drug names to ensure that the intended medicine is supplied
  • if pharmacists have any doubt about which medicine is intended, contact the prescriber before dispensing the drug
  • follow local and professional guidance in relation to checking the right medicine has been dispensed to a patient
  • 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 [SIRMS] that feed into the National Reporting and Learning System