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Look-and Sound-Alike Names

We’re aware of several medication errors related to confusion between the branded drug, SALAGEN (pilocarpine), and a different generic drug, selegiline. Salagen is prescribed for relief of dry mouth symptoms (xerostomia) caused by Sjogren’s syndrome or radiation therapy. Selegiline is a selective inhibitor of monoamine oxidase (MAO) type B, used to treat Parkinson’s disease. Both products are available in 5 mg tablets, although selegiline is also available as ELDEPRYL, a 5 mg capsule. Most recently, a home health nurse received a telephone order from a dentist for an elderly patient with problems related to a dry mouth. He prescribed Salagen 5 mg, but the nurse misheard the order and called the pharmacy to request selegiline 5 mg. About 2 weeks later, another pharmacist was processing a prescription for a fentanyl patch for the same patient when the pharmacy computer system signaled an alert about a drug interaction between fentanyl and selegiline. The error was recognized when the pharmacist contacted the prescriber about the drug interaction. Look-alike errors can also happen. One pharmacist told us that the similar spelling of the drug names led to an error as he was entering a prescription for Salagen into the computer. The error was recognized only after the patient complained that the medication was not helping his dry mouth. The pharmacist checked the patient’s profile and saw that he’d accidentally entered selegiline into the computer. Prescriptions for either of these medications should list both the brand and generic names, and patients should be alerted to the possibility of confusion between these two products.


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