Case studies sought for OTC drug error project

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From the September 11, 1996 issue

We asked for your help last May in helping us to identify patient-related problems with OTCs, especially those that may be related to manufacturers extending use of popular brand names, such as TylenolÒ, AnacinÒ or BufferinÒ for use with a line of products containing different ingredients. Reports are being received about patients who suffered adverse consequences as a result of product confusion. The problem is growing even though awareness by the pharmaceutical industry, FDA and healthcare professionals is increasing. For example, we recently learned about an elderly diabetic woman with knee pain who took AnacinÒ (containing aspirin) for several weeks rather than Anacin-3 (acetaminophen) which was recommended by her doctor. She failed to recognize the difference in ingredients and began to experience vertigo. When her grandson, a health professional, discovered she was taking aspirin, he advised her to stop since it would increase the GlucotrolÒ (glipizide) concentration in her blood, causing hypoglycemia. Had his grandmother not mentioned she was taking AnacinÒ, the outcome might have been much worse. A recent USP Quality Review contains an excellent review of the subject of OTC brand name extensions, including a chart on reported medication errors thus far, and provides suggestions for helping consumers avoid errors with OTCs. It can be obtained by calling 800 487 7776. We would greatly appreciate hearing from health professionals, especially those working as emergency room staff or in drug or poison information centers, if they learn of patients who've suffered an adverse outcome as a result of an error in using an OTC item. Please continue to report recognized problems with OTCs by calling 800 23 ERROR.