From the November 2007 issue

A physician at a rural hospital who was treating an adult victim with ethylene glycol poisoning called a poison center. Staff at the poison center suggested management options, including the use of fomepizole (ANTIZOL). The physician confirmed availability of this drug at the hospital—which was a surprise to poison center staff—so dosing was discussed. Later, the treating physician called the poison center back to check the spelling of the drug. It was then that he learned that he had misheard the poison control staff; he thought the staff had said “omeprazole,” not “fomepizole.” The patient was treated appropriately and no adverse event occurred. Fomepizole is a drug very familiar to poison centers and toxicologists, but it may be unfamiliar to many prescribers since it’s used primarily for methanol and ethylene glycol poisoning. After this event, the poison center staff recognized that they needed to be clear with the information provided to callers who are largely unfamiliar with the unusual therapeutic agents they often recommend. Medications with sound-alike names are particularly problematic in an environment that relies on telephone communication. It is critical for callers to write down and read back drug names. It certainly helps to spell drug names and include brand and generic names when both are known. This experience also reminded the poison center of the need to verify the names of the drugs involved in an overdose as reported by callers, or their advice may be ineffective and even dangerous.