From the October 2007 issue

An apparent medication error in which MATULANE (procarbazine), an antineoplastic agent used to treat Hodgkin’s disease, was dispensed to a pregnant woman instead of the prescribed MATERNA, a pre-natal vitamin, has been reported in the news. According to reports, the patient took Matulane for approximately 2 months and then suffered a miscarriage. While ISMP does not have any other details of the event, there are important lessons that can be shared to prevent similar tragedies. Although the brand product Materna is no longer available in the US, prescribers, who were familiar with this product, may continue to prescribe by this name assuming that a generic substitution will take place. Because Matulane currently is the only U.S. drug that begins with “MAT,” a drug look-up using the first three letters of the name or a mnemonic that begins with “MAT” likely will only produce Matulane, increasing the risk of mix-ups. To prevent errors, avoid using computer mnemonics for Matulane. Consider requiring the full drug name to be typed into computer systems in order to obtain drop down drug listings. Inform physicians that are likely to prescribe either drug about potential errors and reinforce the importance of writing prescriptions with product strength, full dosing information, and indication. Always check the indication of new prescriptions with the patient profile or the patient. Consider storing oral and injectable chemotherapeutic agents separately from other pharmacy stock. Establish a system to ensure that patients receive counseling when picking up new and refilled prescriptions, especially for high-alert medications.