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Another case of name confusion (what else is Neu?)

From the July 29, 1998 issue

PROBLEM: An oncology patient had an appropriately written order for Neumega® (oprelvekin) 3,500 mcg via subcutaneous injection to treat chemotherapy-induced thrombocytopenia. The patient was also receiving Leukine® (sargramostim, GM-CSF) for a low WBC. The patient had been on these agents as an outpatient, having received recent doses in the physician's office just before being admitted for chemotherapy.

A pharmacist misread the order for Neumega as Neupogen® (filgrastim). The 3,500 mcg dose was also misread and the patient received Neupogen 350 mcg via subcutaneous injection. The mistake was discovered after the second dose. The patient was monitored for side effects or lasting sequelae from the Leukine-Neupogen combination, but none were identified. The patient's platelet count was not affected, and his WBC count returned to normal limits within the next two days. However, such an error could be serious if the patient was severely thrombocytopenic and needed the platelet "boost" by Neumega to prevent bleeding. Similarly, a leukopenic patient would receive no benefit from administration of Neumega.

SAFE PRACTICE RECOMMENDATION: These names have identical first syllables and both drugs stimulate the hematopoietic system to increase production of components lost during cancer treatment. The dose of Neumega is 50 mcg/kg/day. The dose of Neupogen is 5 mcg/kg/day. Though a 10 fold difference in the doses exists, the numbers are similar enough to cause confusion, especially if staff are unfamiliar with the drugs. In this case, the dose of 3,500 mcg (versus 350 mcg) went unnoticed, possibly because both drugs were to be given subcutaneously in a small volume. Neumega was not in the computer, but if both drug names had appeared on the screen, it may have helped the pharmacist choose the correct drug. However, it is also important to exercise caution. Medication errors often occur when two similar names appear together on the computer screen, and someone inadvertently chooses the wrong one. In the hospital where the error took place, Neumega is being added to the pharmacy computer, along with some electronic warnings to check the patient's lab values to make sure it is Neumega that is ordered and not Neupogen. Additionally, continuing education is being planned for drugs used in oncology so that all the staff can become more familiar with these complex agents. Physicians prescribing either drug would be wise to include "for platelets" or "for white cells" within the order. This further reduces the likelihood of a mix-up between these two important human growth factors.

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