Avoiding Medication Errors with Multiple Brand Names (April 2009)

The Institute for Safe Medication Practices (ISMP) recently highlighted medication errors that can occur when a drug is marketed under more than one brand name, especially when one of those names is well established.

ISMP describes a case where a female patient went to the emergency department with ischemic chest pain and ECG changes. One of her medications was Revatio, which had been prescribed to treat her pulmonary arterial hypertension. The ED physician reviewed the patient's medication list but did not recognize that Revatio contains sildenafil, the active ingredient in Viagra. The patient was given aspirin and sublingual nitroglycerin, and later was started on an IV nitroglycerin infusion for continued chest pain and elevated troponin-T.

Using organic nitrates in any form, at any time, with sildenafil and similar erectile dysfunction drugs is contraindicated. Fortunately, this patient did not experience adverse effects or blood pressure changes because an internist quickly recognized the problem and stopped the infusion.

ISMP cites other cases where patients received duplicate therapy after taking the same medication prescribed or dispensed under two trade names. These errors have occurred with bupropion (sold as both ZYBAN and WELLBUTRIN), finasteride (sold as PROPECIA and PROSCAR), and fluoxetine (sold as SARAFEM and PROZAC). ISMP says that this type of error may be more likely when the same drug is dispensed from two pharmacies under two different brand names. It is also more likely to happen when a physician prescribes the product by its generic name, but it's dispensed and labeled by its brand name, or when generic products are available under different brand names.

ISMP says that health professionals can reduce the risk of errors by conducting a thorough drug history and reviewing drug information if they encounter unfamiliar product names. ISMP also suggests that health professionals encourage patients to fill their prescriptions at the same pharmacy where possible, to help avoid taking the same product under different names.

Category:

Education

Tags:

• Medication Errors
• FDA
• Patient Safety
• Prescription Errors