More Product Name Mix-Ups

Michael J. Gaunt, PharmD
Published Online: Wednesday, October 1, 2008

Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.


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 prenatal vitamin, has been reported in the news. According to reports, the patient took Matulane for approximately 2 months and then suffered a miscarriage. Although ISMP does not have any other details of the event, important lessons can be shared to prevent similar tragedies. Although Materna is no longer available in the United States, 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 US drug that begins with "MAT," a drug look-up using the first 3 letters of the name or a mnemonic that begins with "MAT" likely will only produce Matulane, increasing the risk of mix-ups.

Figure 1

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 who 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.

Figure 2

Look-Alike Generic Names

A physician wrote a prescription for lamotrigine (Lamictal) 100 mg (see Figure 1). Subsequently, a pharmacist misread the handwritten order as levothyroxine 100 mcg. Lamotrigine is indicated for bipolar disorder and seizures, while levothyroxine is used to treat hypothyroidism. The drugs have overlapping dosage strength numbers (25, 100, 150, and 200) and are administered orally once daily, increasing the risk of mixups. Although the pharmacist dispensed levothyroxine, the error was detected by the patient after reading the patient information leaflet.

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Warn practitioners about the potential for mix-ups with these products. Prescribers should include the indication for use on prescriptions for these drugs. Also, prescribers should write only one medication order per prescription blank. Including more than 1 order, or 2 as in this case above, can make it difficult to interpret the orders and can lead to mix-ups. Pharmacists should counsel patients on all new prescriptions to help avoid mix-ups.

Codeine or Lodine?

A prescriber wrote a prescription for Lodine (etodolac), a nonsteroidal antiinflammatory drug (see Figure 2). A pharmacist interpreted the prescription as codeine, however. Because the prescriber failed to include the dosage strength, directions for use, or quantity, the pharmacist contacted the prescriber and learned that the prescription was actually for Lodine 400 mg, 1 tablet po bid, 60-day supply. Warn your colleagues and other practitioners about the potential for mix-ups with these products. A handwritten "L" can look similar to a "C." Besides including critical information such as dosage strength and directions for use, prescribers should use the generic name etodolac instead of "Lodine" by itself. This will help prevent mix-ups with codeine and avoid confusion with iodine.



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