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Commonly Mixed Up Drug Names That Could Cause Confusion Or Harm

Anytime someone goes into a new doctor, dentist, or has to go to the ER, they may be asked about the medications they are currently taking. Even if someone has been on a drug for years, it may be tough to come up with the name. Unfortunately, some prescription drug names can be easily confused. Alprazolam, clonazepam, and lorazepam could all sound similar but they are very different drugs. 

List of Confused Drug Names

The Institute for Safe Medication Practices (ISMP) has compiled a list of confused drug names that may look-alike or sound-alike. Patients are not likely to know the names of more than a dozen prescription medications. Doctors and pharmacists should be aware of commonly confused drug names and clarify or verify if there is any doubt about what the patient is taking.

According to the Pennsylvania Patient Safety Authority, almost 25% of medication errors reported result from confusion with drug names that sound alike or look alike. With so many drugs out there, many of the drugs end up having similar characters, generic names, or even confusion in the brand-to-generic naming. Combined with illegible handwriting, it is not surprising that another doctor, pharmacist, or the patient could get the drug wrong. 

For example, in one case reported by the ISMP, a patient reported taking Plaxil at home but was really taking Plavix, a common blood thinner. The doctor misinterpreted Plaxil (which is not a drug) as Paxil, a common antidepressant medication. In another example, a doctor had a handwritten order for the bronchodilator Foradil that was misinterpreted as Toradol. 

Reducing Prescription Drug Mix-Ups

There may be a number of ways to reduce the risk of prescription drug confusion or mix-ups. Referring to both the brand name and generic on the prescription and label can help clarify by providing two sources of the drug name. Prescriptions may also include the purpose of the medication, such as “to lower high blood pressure,” to help clarify which drug the patient is taking. 

The Food and Drug Administration (FDA) has established a list of drug names recommended to use the so-called Tall Man Lettering (TML). TML uses mixed case letters to change the appearance of confused drug names, and indicate how they differ. For example, changing:

  • Acetohexamide  —  Acetazolamide


  • acetoHEXAMIDE  —  acetaZOLAMIDE

Looking at the two, without the mixed case lettering, at first glance, the two drugs look very similar. With the mixed lettering, the CAPITAL LETTERS highlight the difference in the names of the drugs. Other examples of drugs using TML to differentiate the drugs include: 

Established Name

Recommended Name






















Prescription Error Attorneys

The effects of a prescription error can be devastating for a patient or their family. Medication errors can result in permanent injury, or even death. The Gilman & Bedigian team is fully equipped to handle the complex steps involved in bringing a malpractice claim. Contact us today for a free consultation.

About the Author

Briggs Bedigian
Briggs Bedigian

H. Briggs Bedigian (“Briggs”) is a founding partner of Gilman & Bedigian, LLC.  Prior to forming Gilman & Bedigian, LLC, Briggs was a partner at Wais, Vogelstein and Bedigian, LLC, where he was the head of the firm’s litigation practice.  Briggs’ legal practice is focused on representing clients involved in medical malpractice and catastrophic personal injury cases. 


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