From the July 26, 2000 issue

Safety Briefs

• In our July 28, 1999, issue, we mentioned that poorly written orders for the anti-diabetic medication AVANDIA (rosiglitazone) can look like COUMADIN (warfarin). Both are available as 4 mg oral tablets, which increases the likelihood of a mix-up. Here's an actual prescription order for Avandia, sent to us recently, that was initially misread as Coumadin.

  
  Picture of order for AVANDIA

  Fortunately, the pharmacist in this case did recognize that the prescription could be interpreted either way, and clarified with the prescriber that Avandia was intended. Since accidental administration of either drug would pose a great danger to any patient, we thought it would be worthwhile to remind physicians, nurses and pharmacists about the potential for errors. To reduce the chance of error, prescriptions for either drug should always include the medication's purpose. Also, nurses and pharmacists must clarify the purpose of either drug prior to dispensing and administration.

• Is this a prescription for TEGRETOL (carbamazepine) or TEQUIN (gatifloxacin)? A straw poll in our office showed that all read the order as Tegretol. But it's actually an order for the antibiotic Tequin. Similarity in the available tablet strengths makes it even easier to misinterpret the drug name.

  
  Picture of order for Tequin

  Carbamazepine is available in 100, 200, and 400 mg (extended release) oral tablets, and Tequin is also available in 200 mg or 400 mg oral tablet strengths. Familiarity and association with the word "equine" seems to invite mispronunciation and misspelling of "Tequin" with an added "E" at the end of the name (which when scripted can look like the "L" in Tegretol). Likewise, unfamiliarity with newer drugs on the market, such as Tequin, invites misinterpretation with other look-alike drug names with which staff are more familiar. As with the Avandia-Coumadin pair above, health professionals should independently confirm the patient's diagnosis before dispensing. Use reminders on drug containers and build alerts for computer systems. Also, an effective formulary addition process, which includes analysis of "error potential" and staff education, can help prevent staff from mistaking orders for newer drugs with older, more familiar drugs.