Medication Mix-ups

A physician hurriedly dashes off a prescription for Diovan® (valsartan), a blood pressure medication. The pharmacist translates the handwritten note and gives the patient Diovol® (magnesium/aluminum/simethicone), a drug to relieve heartburn. Several weeks later, the patient’s blood pressure is still too high.

Mistakes like this hypothetical one happen too often, says Matthew Grissinger, RPh, FASCP, Director of Error Reporting Programs at the Institute for Safe Medication Practices (ISMP). More than 1,500 sound-alike drugs exist in the U.S. marketplace, according to ISMP, and that makes it too easy for patients to accidentally get the wrong medication.

Look-alike packaging can add to the confusion. A patient with diabetes, for example, might receive Lantus® (insulin glargine), a long-acting insulin, instead of Apidra® (insulin glulisine), a rapid-action insulin, because both look the same. But taking the wrong insulin may result in a patient’s glucose level becoming dangerously high or dangerously low, says Ramona Davis, RPh, PharmD, Cleveland Clinic Director of Medication Safety Services.

Dr. Davis says Cleveland Clinic pharmacists have taken steps to ensure patient safety. These measures include “tall man lettering” — using capital letters to differentiate drugs such as acetoHEXAMIDE, a diabetes drug, and acetoZOLAMIDE, a glaucoma drug. Pharmacists also do not store similar-sounding or similarly packaged drugs beside each other.

In addition, Cleveland Clinic doctors now type their prescriptions into computers, effectively eliminating penmanship problems. Still, patient diligence is important too, Dr. Davis says: “Know what your doctor has written for you, and ask what that prescription is for.”