Drug Name Confusion: Salagen and Selegiline (Feb 2006)

The Institute for Safe Medication Practices recently described several cases where the brand name of one drug was mistaken for the generic name of another. Salagen, a brand name for pilocarpine, is used to treat the dry mouth symptoms caused by Sjogren's syndrome or radiation therapy. Selegiline is an MAO-inhibitor used to treat Parkinson's disease. Both drugs are available in 5 mg tablets.

In the first case, the mix-up occurred because the names sounded alike. A home health nurse received a telephone order from a dentist for an elderly patient with problems related to a dry mouth. The dentist prescribed Salagen 5 mg, but the nurse misheard the order and called the pharmacy to request selegiline 5 mg. About 2 weeks later, another pharmacist was processing a prescription for a fentanyl patch for the same patient when the pharmacy computer system signaled an alert about a drug interaction between fentanyl and selegiline. When the pharmacist contacted the prescriber, he discovered the error.

In the second case, a pharmacist reported that the similar spelling of the two drug names led him to enter "selegiline" into the computer instead of "Salagen". The error was recognized only after the patient complained that the medication was not helping his dry mouth, and this caused the pharmacist to check the patient's profile.

In order to minimize these kinds of mix-ups, ISMP says to list both the brand and generic names on prescriptions. And patients who use these drugs regularly should be alerted to report any change in the appearance of their medications.

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Tags:

• Drug
• Confusion
• Salagen
• Selegiline
• Pilocarpine
• Sjogren's
• Syndrome
• Radiation
• Therapy
• FDA
• MAO-inhibitor
• Parkinson's
• Disease