Table 1.
List of Highest Decile of LASA Errors, Ranked by Potential Harm of Receiving the Delivered Drug in Error
| Generic Name of Delivered Drug | Published Name of Delivered Drug* | Published Name of Intended Drug† | Generic Name of Intended Drug | Average Harm Score‡ | No. of Subjects§ |
|---|---|---|---|---|---|
| Potassium | K Dur | Kayexalate | Sodium polystyrene sulfonate | 93 | 0 |
| Cyclosporine | Cyclosporine | Cyclophosphamide | Cyclophosphamide | 92 | 5 |
| Digoxin | Lanoxin | Levothyroxine | Levothyroxine | 92 | 15 |
| Warfarin | Coumadin | Cardura | Doxazosin | 91 | 5 |
| Warfarin | Jantoven | Januvia | Sitagliptin | 90 | 1 |
| Warfarin | Warfarin | Levaquin | Levofloxacin | 90 | 52 |
| Warfarin | Coumadin | Mephyton | Phytonadione | 89 | 5 |
| Warfarin | Coumadin | Avandia | Rosiglitazone | 88 | 2 |
| Warfarin | Jantoven | Janumet | Sitagliptin + Metformin | 88 | 0 |
| Azathioprine | Azathioprine | Azithromycin | Azithromycin | 87 | 63 |
| Temozolomide | Temodar | Tambocor | Flecainide | 86 | 0 |
| Cyclophosphamide | Cyclophosphamide | Cyclosporine | Cyclosporine | 85 | 5 |
| Disopyramide | Disopyramide | Desipramine | Desipramine | 85 | 0 |
| Lithium | Eskalith | Effexor | Venlafaxine | 85 | 99 |
| Letrozole | Femara | Famvir | Famciclovir | 85 | 0 |
| Labetalol | Labetalol | Albuterol | Albuterol | 85 | 40 |
| Lithium | Lithium | Lanthanum | Lanthanum | 85 | 0 |
| Amiodarone | Amiodarone | Amlodipine | Amlodipine | 84 | 3 |
| Glipizide | Glucotrol | Detrol | Tolterodine | 84 | 1 |
| Nitroglycerin | Nitro Bid | Macrobid | Nitrofurantoin | 84 | 5 |
| Flecainide | Tambocor | Tamoxifen | Tamoxifen | 84 | 0 |
| Alprazolam | Xanax | Atarax | Hydroxyzine | 84 | 430 |
| Hydromorphone | Hydromorphone | Haloperidol | Haloperidol | 83 | 0 |
| Levorphanol | Levorphanol | Levothyroxine | Levothyroxine | 83 | 0 |
| Capecitabine | Xeloda | Xenical | Orlistat | 83 | 0 |
| Anastrazole | Arimidex | Aromasin | Exemestane | 82 | 0 |
| Clomipramine | Clomipramine | Clozapine | Clozapine | 82 | 1 |
| Clomipramine | Clomipramine | Clomid | Clomiphene | 82 | 0 |
| Cyclosporine | Cyclosporine | Cycloserine | Cycloserine | 82 | 0 |
| Diazoxide | Diazoxide | Diamox | Acetazolamide | 82 | 0 |
| Fludrocortisone | Florinef | Fioricet | Butalbital + acetaminophen + caffeine | 82 | 0 |
| Methadone | Methadone | Methylphenidate | Methylphenidate | 82 | 9 |
| Morphine | Morphine | Magnesium Sulfate | Magnesium Sulfate | 82 | 0 |
| Nifedipine | Nifedipine | Nortriptyline | Nortriptyline | 82 | 1 |
| Digoxin | Lanoxin | Lotensin | Benazepril | 81 | 18 |
| Tamoxifen | Nolvadex | Flomax | Tamsulosin | 81 | 0 |
| Amlodipine | Amlodipine | Amiodarone | Amiodarone | 80 | 3 |
| Metoprolol | Lopressor | Lyrica | Pregabalin | 80 | 5 |
| Amiodarone | Pacerone | Pancrease | Pancrelipase | 80 | 3 |
| Midodrine | ProAmatine | Bromocriptine | Bromocriptine | 80 | 0 |
| Tacrolimus | Tacrolimus | Tamsulosin | Tamsulosin | 80 | 0 |
| Digoxin | Lanoxin | Lasix | Furosemide | 79 | 447 |
| Chlorambucil | Leukeran | Leucovorin | Leucovorin | 79 | 0 |
| Hydrocodone + Acetaminophen | Lortab | Loratadine | Loratadine | 79 | 8259 |
| Loxapine | Loxitane | Soriatane | Acitretin | 79 | 0 |
| Methotrexate | Methotrexate | Minoxidil | Minoxidil | 79 | 0 |
| Procainamide | Procanbid | Probenecid | Probenecid | 79 | 0 |
| Reserpine | Reserpine | Ropinirole | Ropinirole | 79 | 0 |
| Rosiglitazone + Metformin | Avandamet | Anzemet | Dolasetron | 78 | 0 |
| Chlorpromazine | Chlorpromazine | Clomipramine | Clomipramine | 78 | 2 |
| Clozapine | Clozaril | Pletal | Cilostazol | 78 | 0 |
| Digoxin | Lanoxin | Levsin | Hyoscyamine | 78 | 24 |
| Methadone | Methadone | Mephyton | Phytonadione | 78 | 1 |
| Methimazole | Methimazole | Metaxalone | Metaxalone | 78 | 6 |
| Nitroglycerin | Nitroglycerin | Nitrofurantoin | Nitrofurantoin | 78 | 5 |
| Sitagliptin + Metformin | Janumet | Jantoven | Warfarin | 77 | 0 |
| Theophylline | Slow Bid | Slow K | Potassium | 77 | 0 |
| Hydrocodone + Acetaminophen | Vicodin | Vytorin | Ezetimibe + simvastatin | 77 | 20 |
| Digoxin | Lanoxin | Lomotil | Diphenoxylate + atropine | 76 | 7 |
| Digoxin | Lanoxin | Levaquin | Levofloxacin | 76 | 24 |
LASA indicates look alike, sound alike.
Bold type indicates that LASA pair is in highest decile for potential harm for receiving delivered drug in error and highest decile for potential harm of not receiving intended drug. Brand names appear in italic type.
Delivered drug indicates drug received in error.
Intended drug indicates drug patient was supposed to receive.
Average harm score represents the average of round 3 evaluations of the opinion-generated estimate of the harm that might occur from this substitution, where patient received delivered drug instead of intended drug.
Number of subjects in 2000–2009 data who received both drugs in respective LASA pair within 6-month period, regardless of whether this was intended or in error. Each occurrence represents potential LASA substitution error.