Medication Mistakes

Even the seemingly simple process of giving a patient medicine--the right drug, in the right dose, to the right patient, at the right time--is, in reality, teeming with opportunities for error. The IOM estimates that preventable medication errors result in more than 7,000 deaths each year in hospitals alone, and tens of thousands more in outpatient facilities.

Name confusion is among the most common causes of drug-related errors, says Peter Honig, M.D., an FDA expert on drug risk-assessment. A recent example: the sound-alike names for the antiepileptic drug Lamictal and the antifungal drug Lamisil. The volume of dispensing errors involving these two drugs prompted the manufacturer of Lamictal, Glaxo Wellcome Inc., of Research Triangle Park, N.C., to launch a campaign warning pharmacists of the potential confusion. The possible consequences of prescribing the wrong drug are grave: Epileptic patients receiving the anti-fungal drug Lamisil by mistake could experience continuous seizures. Patients erroneously receiving the antiepileptic drug Lamictal might experience a serious rash, blood pressure changes, or other side effects.

Errors also have occurred in prescribing the arthritis drug Celebrex, the anticonvulsant Cerebyx, and the antidepressant Celexa. There have been well over 100 reports of confusion among the three drugs, none of which has resulted in serious harm to a patient.