Amantadine and Memantine
During a recent internship, a pharmacy
student was asked by 2 physicians
and 1 pharmacist for "information
about the newer drug to treat
Alzheimer's disease, amantadine."The
student initially responded by saying
that she thought that amantadine
(Symmetrel) had been around for a
while. That drug is indicated in the prophylaxis
and treatment of signs and
symptoms of infection caused by various
strains of influenza A virus and in
the treatment of parkinsonism and
drug-induced extrapyramidal reactions.
After investigating, however, the student
realized that the medication in
question was actually memantine
(Namenda). It is indicated for the treatment
of moderate-to-severe dementia of
the Alzheimer's type. It became available
in the United States in January 2004.
Normodyne and Norpramin
At a community pharmacy, a
woman presented a prescription for
what was supposed to be Normodyne
(labetalol) 100 mg bid, but it was misinterpreted
as the tricyclic antidepressant
Norpramin (desipramine) 100 mg
bid. After taking 1 dose, the woman
experienced nausea, blurred vision,
sweating, and hand tremors.
Subsequently, she performed a computer
search on Norpramin. Because she
knew that she was supposed to receive
an antihypertensive, she realized that
she was given the wrong medication.
Similarities in the drug name, dosage,
and frequency of administration likely
contributed to the error. The error might
have been avoided if adequate counseling
or a medication information leaflet
had been provided at the pharmacy.
Avinza and Evista
Beware of look-and sound-alike
problems between Avinza (morphine
sulfate extended release), used in the
treatment of moderate-to-severe pain,
and Evista (raloxifene), used in the
treatment and prevention of osteoporosis
in postmenopausal women. In
a recent error, a pharmacist received a
handwritten physician's order for Avinza
60 mg daily; however, the order was
misinterpreted as Evista 60 mg daily.
The patient was a 75-year-old
female, so the error was not immediately
recognized. The error was discovered
2 days later when the physician
wrote an order to increase the
Avinza to 90 mg daily because the
patient's pain was not controlled.
Similarities in the drug names, overlapping
dosage (60 mg), and similar
once-daily dosing likely contributed
to the error. Had the prescriber listed
the indication for the medication on
the order, it would have helped to prevent
this error. Because of the soundalike
potential, these drug names
should be spelled out when giving
telephone or verbal orders.
Norvasc and Navane
A patient admitted to a psychiatry
service had orders written for fluoxetine
60 mg daily and what appeared to
be Norvasc (amlodipine) 5 mg twice
daily. One dose of Norvasc was dispensed
and administered before a
nurse contacted another pharmacist
to request a missing dose of Navane
(thiothixene). The pharmacist reviewed
the patient's profile and did
not see an order for Navane. He
noticed an order for Norvasc, however,
for the same strength and frequency.
The pharmacist, who was aware of
reported mix-ups between these
agents, retrieved the original order
and discovered that, indeed, the order
was for Navane, not Norvasc.
The correct drug was dispensed, and
the nursing staff was alerted to observe
the patient for possible hypotension
over the next 12 to 24 hours. The
patient experienced no apparent
adverse effects from the Norvasc
administration or from the temporary
delay in receiving Navane.
When Norvasc was first marketed, the
Institute for Safe Medication Practices
received numerous reports about erroneous
dispensing of Navane. Now that
Norvasc is so widely used, the opposite
mix-up occurs more frequently. This
report should serve as a reminder that
this pair of look-alike names continues
to present problems.
Dr. Kelly is the editor of ISMP
Medication Safety Alert! Community/Ambulatory Care Edition.
The reports described here were
received through the USP Medication
Errors Reporting Program, which is presented
in cooperation with the Institute
for Safe Medication Practices (ISMP).
ISMP is a nonprofit organization whose
mission is to understand the causes of
medication errors and to provide time-critical
error-reduction strategies to the
health care community, policy makers,
and the public. Throughout this series,
the underlying system causes of medication
errors will be presented to help readers
identify system changes that can
strengthen the safety of their operation.
If you have encountered medication
errors and would like to report
them, you may call ISMP at 800-324-5723 (800-FAILSAFE) or USP at 800-233-7767 (800-23-ERROR). ISMP's
Web address is www.ismp.org.
Pharmacy Times and the Institute
for Safe Medication Practices (ISMP)
would like to make community pharmacy
practitioners aware of a publication
that is available.
The ISMP Medication Safety Alert!
Community/Ambulatory Care Edition is
a monthly compilation of medicationrelated
incidents, error-prevention recommendations,
news, and editorial
content designed to inform and alert
community pharmacy practitioners to
potentially hazardous situations that
may affect patient safety. Individual
subscription prices are $45 per year
for 12 monthly issues. Discounts are
available for organizations with multiple
pharmacy sites. This newsletter is
delivered electronically. For more information,
contact ISMP at 215-947-7797, or send an e-mail message to