From the May 6, 2004 issue

While preparing for a cataract procedure, an OR nurse went into the refrigerator to obtain sodium hyaluronate. She quickly noticed two different products. One was sodium hyaluronate 10 mg/mL (HEALON), manufactured by Pharmacia; the other was sodium hyaluronate 20 mg/ 2 mL (HYALGAN), manufactured by Sanofi-Synthelabo. The nurse looked at each product and realized that they were the "same" medication (sodium hyaluronate) in the same concentration (see photo), so she decided to use Hyalgan for the cataract case. However, as soon as the surgeon began using the product, he immediately noticed that the fluid was much different in viscosity than what he typically used. He withdrew what he had just injected and asked for Healon instead. The surgery was completed and the patient fared well.

Although both products contain the same basic chemical, Hyalgan is designed for injection into joints. It is typically used to treat pain and help restore normal joint function in osteoarthritis where the elastoviscous properties of the synovial fluid in the knee joint diminish, resulting in less protection and shock absorption. Healon is a viscoelastic used as a surgical aid in cataract extraction and intraocular lens implantation. It is also indicated for use in glaucoma filtration and posterior segment procedures. On the side of the Healon carton is a note stating that the product is intended for ophthalmic use. The carton of a similar product, AMVISC, has such a notation, but it also has a large picture of an intraocular injection, clarifying its intended use. Hyalgan does not state the purpose of the drug on the outside carton.

To prevent dispensing errors in facilities where both products are available, add an auxiliary label to the cartons to remind staff about each drug's indication (ophthalmology or orthopedics).