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Child suffers glaucoma from inadvertent use of corticosteroid-containing eye drops

From the June 30, 1999 issue

PROBLEM:A pediatric ophthalmologist prescribed TOBREX (tobramycin) 0.3% ophthalmic drops for a one-month-old infant with a blocked tear duct (one drop TID to the left eye). The physician indicated this drug by checking off a space on a preprinted prescription order form which listed 12 different ophthalmic drops (see picture below) including TOBRADEX (tobramycin and dexamethasone) which appeared on the line above Tobrex. Somehow, the pharmacist misread the prescription order and erroneously dispensed Tobradex. Compounding the error, the pharmacist refilled the prescription with Tobradex when the initial supply was exhausted. When the infant's eye continued to worsen, the mother returned to the ophthalmologist. Under general anesthesia for a complete examination, the physician made a diagnosis of non-congenital, steroid-induced (dexamethasone) glaucoma. Surgery may be required.

Fig. 1    Picture of Preprinted Rrescription Blank

SAFE PRACTICE RECOMMENDATION:The case raises several safety issues, including increasing concerns about look-alike/sound-alike names (we've had several reports of mix-ups between Tobrex and Tobradex in the past) and the need for FDA to have manufacturers properly test pharmaceutical trademarks for safety prior to drug approval. Also, the use of preprinted prescriptions that list drugs in vertical columns, with spaces to tick or enter the dose of required medication, is not a safe practice since it's easy to accidentally indicate the wrong drug by marking the wrong space or read the wrong drug. If these forms are to be used at all, they must be designed in a way that assures drugs with similar names do not appear in close proximity. In our February 14, 1996 issue, we wrote about a case where an oncologist entered "360 mg" in the space beside the cisplatin (PLATINOL) listing on a preprinted chemotherapy order form instead of next to carboplatin (PARAPLATIN). This resulted in a massive overdose of cisplatin.

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