Table 2

Confirmed errors, with suspected intended medication, similarity level and number of occurrences

Similarity levelMedication orderedMedication intendedNumber of occurrencesPreviously published case report
10CycloserineCiclosporin*9Yes
9ButabarbitalButalbital1Yes
8HydralazineHydroxyzine3Yes
8HydroxyzineHydralazine2Yes
8SulfadiazineSulfasalazine5Yes
8ValacyclovirValganciclovir3Yes
8ValganciclovirValacyclovir12Yes
7ClomipheneClomipramine3Yes
7ClomipramineClomiphene1Yes
7RifampinRifaximin1Yes
6CyclobenzaprineCiclosporin1Yes
6LactaseLactulose2No
6Methohexital*Methotrexate*1Yes
5CilastatinCilostazol1No
5SumatriptanSomatropin1No
4DicyclomineDoxycycline1Yes
3DiphenhydramineDesipramine1No
3LevocetirizineLevothyroxine1No
3LoratadineLovastatin1No
3MetolazoneMetoclopramide1Yes
3Metoprolol*Metoclopramide1Yes
3NitrofurantoinNitroglycerin1Yes
3TizanidineRanitidine1No
2AzathioprineAzithromycin1Yes
2EscitalopramEnalapril2Yes
2LevocarnitineLevofloxacin1No
1CholestyramineChlorpromazine1No
1HydrochlorothiazideHydroxyzine1Yes
1HydroxyzineHydrochlorothiazide1Yes
  • An asterisk indicates that the drug is on the Institute for Safe Medication Practices’ list of high-alert medications.