From the June 2009 issue

A prescriber’s office sent an electronic (eRx) prescription to the patient’s pharmacy; the prescriber intended to prescribe VESICARE (solifenacin succinate) for overactive bladder but inadvertently selected VESANOID (tretinoin) which is used to induce remission of acute promyelocytic leukemia (APL). The pharmacy technician entered the prescription for generic tretinoin; however, the pharmacy was unable to dispense the medication as the patient’s pharmacy benefit manager required a prior authorization. The technician faxed a request, and the prescriber’s office replied back that Vesicare was intended. Both of these products are available in 10 mg solid oral dosage forms, increasing the risk of confusion. Investigate strategies (e.g., tall man letters) to differentiate these products on computer screens. Prescribers should include the indication for the drug with the prescription. As always, providing patient education, especially for new prescriptions, is a good strategy to intercept errors before they impact the patient.