From the December 2008 issue

A pharmacist reported a mix-up between benazepril (LOTENSIN) and BENADRYL (diphenhydramine). A patient faxed a request to the pharmacy to ask for her “benazapryl.” The pharmacist who received the fax interpreted it as Benadryl and placed a bottle of diphenhydramine in the bag for pick-up. Around this same time, the pharmacy went through a change in wholesaler and many manufacturers of generic products were changed. A few days later, a co-worker of the patient picked up the medication (along with several others). The technician at the point-of-sale told the co-worker that many of the manufacturers had changed recently and that some of the pills may look different. The patient received the diphenhydramine, filled her medication box with the capsules, and took diphenhydramine daily for 3 weeks before noticing she was unusually tired. When she brought the bottle back to the pharmacy, the error was recognized.