Mixed-Up Meds

By Christine Gorman

Mistakes are a fact of life (and sometimes death) in any hospital, but one of the easiest to make, according to the report published last week by the Institute of Medicine (see story this week in MEDICINE), is to confuse one drug for another. Fortunately, this is a source of medical error that patients can do something about.

I speak from personal experience. As a college student in the 1980s, I spent a summer working as an intern in a hospital pharmacy. Whenever we received a prescription order, I would go to the stock shelves, find the right bottle and count out the number of pills that were called for. A registered pharmacist verified my work and swept the pills into a container with the patient's name, which was then delivered to the appropriate floor. One day I put a weaker dose of a heart medication on the counting tray than I should have. Neither the pharmacist nor I caught my mistake, but the patient saw that the pills were not the color he was used to getting and refused to take the drug. That episode taught me that mistakes can happen, even when safeguards are in place. And whether we like it or not, patients are sometimes the last line of defense against errors.

The potential for medication mix-ups has increased dramatically over the past two decades as more and more drugs--each with one or more generic and brand names--have flooded the market. There are more than 15,000 drug names in general use in the U.S. With only 26 letters in the alphabet, some of these names are bound to sound alike.

For example, soon after the new arthritis drug Celebrex became available, the Food and Drug Administration received 53 reports of dispensing errors that occurred when it was mistaken for the seizure drug Cerebyx or the antidepressant Celexa. Searle, the maker of Celebrex, ran ads in medical journals this summer to point out the similarities to doctors and pharmacists and make them aware of the dangers of mixing them up. Although the FDA regulates drugs for safety and efficacy, it does not pay as close attention to their names.

Other commonly confused drugs, according to the Institute for Safe Medication Practices, include Flomax (used to treat an enlarged prostate) and Fosamax (osteoporosis), Adderall (attention-deficit disorder) and Inderal (high blood pressure or heart problems), Lamisil (fungal infections) and Lamictal (epilepsy), Prilosec (acid reflux) and Prozac (depression).

As the patient in my own close call showed, knowing the color and shape of the pills you take regularly is an important safeguard against taking the wrong one. Many new drugs have their own websites, complete with pictures. Another excellent source of visual information is the Physician's Desk Reference, which is available in many libraries. There's lots more information on the Web at www.pdr.net

It's also a good idea to ask your doctor to write out both the generic and brand names of your prescription. Find out from him or her what condition the drug is supposed to treat, how to take it and what possible side effects you might expect. Then, as a check, ask those same questions of the pharmacist who fills the order. Most of the time there won't be a problem. But it never hurts to learn all you can about what you're putting in your body.

For more information on medication errors, visit time.com/personal You can send e-mail for Christine to gorman@time.com