Drug name mix-ups: Much more than
From the July 1 , 1998 issue
PROBLEM: We received several reports concerning possible
confusion between Flomax® (tamsulosin), an alpha-1-adrenergic
blocker used for benign prostatic hypertrophy, and Fosamax®
(alendronate), a drug chiefly used in post-menopausal osteoporosis.
Confusion between these names recently resulted in a mix-up.
A physician wrote an order for "Flomax 1 q.d." Poor handwriting
prompted the pharmacist to ask nursing to obtain order clarification.
Nursing spoke with the patient's community pharmacist and
determined that the patient had been taking Flomax 0.4 mg
daily. By the time this information was obtained, the hospital
pharmacy was closed for the day. The evening nurse manager
entered the pharmacy and accidentally filled the order with
Fosamax 10 mg, leaving behind a note for the pharmacist. The
next day, the pharmacist assumed that the order had been clarified
as Fosamax, and entered this drug into the computer. Although
Flomax was indicated on the medication administration record
(MAR), the error continued for three days.
Along with look-alike drug names and poor physician handwriting,
additional issues contributed to this error. The physician's
order was incomplete - no dose was specified. Had a dose of
0.4 mg been ordered, staff would have been less likely to
confuse Flomax with Fosamax. Had the pharmacist obtained clarification
directly from the prescriber, the correct drug most likely
would have been dispensed prior to pharmacy closing. Without
24 hour pharmacy services, the nursing supervisor was given
access to the pharmacy for drug dispensing. Unfamiliarity
with all the various drugs and dosage forms in the pharmacy,
and bypassing computer order screening, are just a few of
the problems that make this practice unsafe.
SAFE PRACTICE RECOMMENDATION: All drug orders must
specify a dose, even if the drug is only available in one
strength. Pharmacists must take an active - never passive
- role in clarifying drug orders. Delegation to other practitioners
results in indirect communication of pharmacy concerns with
the prescriber, which is an error-prone practice. Always clarify
orders with the prescriber. A carefully selected supply of
drugs should be available in dispensing modules for use when
the pharmacy is closed. Warnings should be added to the computer
to alert staff to the potential for mix-ups between Flomax
and Fosamax. Basic information about the patient and drug
must be considered. An understanding by the nurses and pharmacists
that Fosamax is used in post-menopausal osteoporosis in females
and Flomax is used for benign prostatic hypertrophy in males,
would have prevented the error. Although not directly causing
this error, an additional problem is noted. The physician
used the abbreviation "q.d." in the drug order, which is often
misinterpreted as "qid." Write out "daily" instead.