Reminder for GP Colleagues and Pharmacists
GP colleagues and pharmacists are being reminded to apply caution when prescribing
or dispensing two similar sounding medications.
Surrey and Borders NHS Partnership Trust (SABP) has highlighted incidents where
Promazine, an anti-psychotic medication, and similar sounding promethazine, an
antihistamine medication, have been accidentally confused and therefore incorrectly
prescribed by clinicians outside of the Trust.
The two medications are known as ‘look alike sound alike’ (LASA) medications. As well
as having similar sounding names, similarities can also sometimes be compounded by
other factors such as similar packaging, tablet appearance and tablet strength.
SABP is aware of cases where promazine and promethazine have been confused, either
in the prescribing or dispensing stage. There is also the possibility that the two
medicines may have been mistakenly referred to within electronic patient records
during the documenting of encounters.
Primary and secondary care medicines safety colleagues across Surrey Heartlands and
Frimley Health and Care are reviewing cases across their respective areas where
promazine has been prescribed to check whether the drug has been administered in
error. Where such cases are identified, a case note review will be carried out to
determine the intended medicine. Appropriate plans will then be put in place to discuss
identified cases with all relevant teams involved in the individual’s care.
Additionally, where feasible, alerts are being implemented in electronic prescribing and
dispensing systems, highlighting the similarity between the names promazine and
promethazine. This will, where feasible, flag up to GPs, clinicians and pharmacists
prescribing or administering promazine requests for them to re-check that they have
selected the correct medication.
For more details contact:
Alison.marshall@sabp.nhs.uk (Medicines Safety Officer –SABP)
Nikki.smith24@nhs.net (Head of Medicines Safety, Surrey Heartlands)
Melody.chapman@nhs.net (Medicines Safety Lead, Frimley Health)
Frimley Medicines Optimisation team
NHS Frimley
