Drug-name mix-ups hurt patients, getting worse

[flashl]

WASHINGTON (Reuters) - Dr. Julius Pham's stomach churned when he saw a critically ill heart patient getting an antibiotic instead of a drug to support his blood pressure -- the kind of mix-up that is increasingly common in the United States, according to a new report.

"If you have ever had that sinking feeling that drops to the bottom of your stomach, I had it," Pham, then a critical care physician at Johns Hopkins University in Baltimore, told reporters. "Unfortunately, the patient did not do well."

A nurse had confused Levophed, which can boost blood pressure, with the antibiotic Levaquin.

The rate of drug name mix-ups has more than doubled since 2004, the U.S. Pharmacopeia said in a report on Tuesday.

Reuters

What is the solution to drug-name mix-ups?

[Vinca]

1. This has always been a problem.

I once worked for a doctor who had a patient who nearly died after a pharmacist mixed up Digoxin and Digitoxin. One problem with current drugs are the cutesy names that almost always have a "z" in them.

[Warpy]

5. Remember quinine vs. quinaglute?

Thank gawd that patient had the heart of a healthy ox and was susceptible to the placebo effect for her nocturnal leg cramps!

I yelled at somebody for that one, one of the few times I ever yelled at a coworker.

[Liberal Veteran]

6. quinine vs. quinidine was always my pet peeve.

[trotsky]

2. I am not a doctor or a pharmacist.

But I have to wonder if a simple solution to this would be that in addition to writing the drug name, provide just a brief description to confirm the intention.

E.g., "15 mg Levophed - inc. blood pressure"

That way if the description doesn't match up with what the drug is known to do, someone might have a better chance of catching it.

[dropkickpa]

3. My PCP actually does this

All prescriptions get "for xxxx" on them in addition to the usual stuff.

[Warpy]

4. Levophed versus Levaquin? Didn't s/he look at the PATIENT?

That one is unforgivable.

We used to call Levophed "Leave 'em dead" because it was a last line drug used to support blood pressure when everything else had failed.

While the bottomed out blood pressure might have been caused by toxic shock that required an antibiotic as well as blood pressure support, this one should have been questioned closely.

Something tells me a nurse is going to be hung out to dry.

Having physicians type their orders directly into a computer will help, but this one sounds like a phone order in the middle of the night when the doc wasn't speaking all that clearly. However, any nurse calling about a patient with a blood pressure in the dumper should have known what drug was being prescribed for it. The best antibiotic in the world won't do a damned thing for it for days. Meanwhile, the patient is severely compromised or dead.

Big Pill is running out of names, though. It's getting to the point where docs are going to have to specify things like "GI: Zantac" versus "Psych: Xanax" in their verbal orders.

[Celebration]

7. Hmmm

Sounds like the linguistics majors need to be employed by the drug companies.........or the FDA. I thought boxes had to be checked off for purpose of the drugs--if only for insurance reasons.