MHRA issues call to remain ‘vigilant’ with commonly confused drug names

Prescribers and dispensers are asked to take care when working with certain medicines with similar-sounding names.

Man reads prescription bottle

The Medicines and Healthcare products Regulatory Agency (MHRA) has asked prescribers and dispensers to remain vigilant with “commonly confused” medicines.

In a support alert issued on 9 January 2018, the regulatory body said that since April 2013, when its last drug safety update on drug-name confusion was issued, it had received yellow card reports of harm following confusion between six pairs of drugs:

  • Clobazam/clonazepam
  • Atenolol/amlodipine
  • Propranolol/prednisolone
  • Risperidone/ropinirole
  • Sulfadiazine/sulfasalazine
  • Amlodipine/nimodipine

A spokesperson for the MHRA said: “We hope that the recent drug safety update article will remind all healthcare professionals of the need to be vigilant about so-called ‘sound-alike, look-alike’ drugs.

“The article lists the six pairs of medicines for which we have received reports of harm resulting from drug-name confusion since our last drug safety update on the topic in 2013.

“We are aware that other cases that did not result in harm will have been reported through other systems and we do not intend for our article to be a conclusive list of ‘sound-alike, look-alike’ drugs. However we would encourage all pharmacists to consider the advice and discuss ideas for best practice with their colleagues.”

Inadvertent dispensing errors involving confusion between propranolol and prednisolone have been the subject of two high-profile prosecutions of pharmacists in recent years: Elizabeth Lee in 2009, and Martin White in 2016.

On 6 December 2017 new legislation to protect community pharmacists from prosecution over inadvertent dispensing errors was passed by committees in the House of Lords and the House of Commons. To be passed into law, the legislation must now be approved by both full houses and then signed by the Privy Council.

Last updated
The Pharmaceutical Journal, MHRA issues call to remain 'vigilant' with commonly confused drug names;Online:DOI:10.1211/PJ.2018.20204231

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