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From the July 26, 2000 issue
Safety Briefs
- In our July 28, 1999, issue, we mentioned that poorly
written orders for the anti-diabetic medication AVANDIA
(rosiglitazone) can look like COUMADIN (warfarin). Both
are available as 4 mg oral tablets, which increases the
likelihood of a mix-up. Here's an actual prescription order
for Avandia, sent to us recently, that was initially misread
as Coumadin.
Picture of order for AVANDIA
Fortunately, the pharmacist in this case did recognize
that the prescription could be interpreted either way,
and clarified with the prescriber that Avandia was intended.
Since accidental administration of either drug would pose
a great danger to any patient, we thought it would be
worthwhile to remind physicians, nurses and pharmacists
about the potential for errors. To reduce the chance of
error, prescriptions for either drug should always include
the medication's purpose. Also, nurses and pharmacists
must clarify the purpose of either drug prior to dispensing
and administration.
- Is this a prescription for TEGRETOL (carbamazepine) or
TEQUIN (gatifloxacin)? A straw poll in our office showed
that all read the order as Tegretol. But it's actually an
order for the antibiotic Tequin. Similarity in the available
tablet strengths makes it even easier to misinterpret the
drug name.
Picture of order for Tequin
Carbamazepine is available in 100, 200, and 400 mg (extended
release) oral tablets, and Tequin is also available in
200 mg or 400 mg oral tablet strengths. Familiarity and
association with the word "equine" seems to invite mispronunciation
and misspelling of "Tequin" with an added "E" at the end
of the name (which when scripted can look like the "L"
in Tegretol). Likewise, unfamiliarity with newer drugs
on the market, such as Tequin, invites misinterpretation
with other look-alike drug names with which staff are
more familiar. As with the Avandia-Coumadin pair above,
health professionals should independently confirm the
patient's diagnosis before dispensing. Use reminders on
drug containers and build alerts for computer systems.
Also, an effective formulary addition process, which includes
analysis of "error potential" and staff education, can
help prevent staff from mistaking orders for newer drugs
with older, more familiar drugs.
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