MNP-POL-001: Look-alike and sound-alike medicines

Policy · MNP-POL-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 3.1

At a glance

Look-alike and sound-alike medicines are named on a single list, kept current.
Each listed medicine has a safeguard: separated storage, distinct labelling or an independent check.
The list is shared with pharmacy, wards and theatres.
Near misses with listed medicines are reported and reviewed.
Stop and get help straight away if: a listed medicine is stored or labelled like any other, or a near miss is not reported.

1. Purpose

To prevent dispensing errors between medicines that look or sound alike (3.1).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

Two drugs that look or sound alike are a common cause of serious dispensing errors. Naming them on a list and giving them distinct safeguards stops a mix-up before it reaches the patient.

5. Responsibilities

Role	Responsibility	Competence
Chief pharmacist	Owns the list and the safeguards	Pharmacist
Ward managers	Apply the safeguards on the ward	Management

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Identify.

Keep the list of look-alike and sound-alike medicines current (MNP-REG-001).

Key point: One list, used everywhere.

Step 2. Safeguard.

Store listed medicines apart, label them distinctly, and apply an independent check before dispensing or giving.

Key point: Each listed medicine has a safeguard.

Step 3. Report.

Report any near miss involving a listed medicine on the incident system the same day.

Key point: Near misses teach the system.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Listed medicines with a safeguard in place	100%	Quarterly	Chief pharmacist	Escalate to chief executive
Near misses reported and reviewed	100%	Monthly	Chief pharmacist	Escalate to chief executive

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
MNP-REG-001	Look-alike and sound-alike medicines list	List
HOS-SOP-006	High-alert medicines	Procedure
HOS-FRM-005	High-alert second-check record	Second check

17. Evidence

Reference	Note
E-009	Based on the ISMP List of Confused Drug Names.
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

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References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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