Mistakes are common in any profession, and often expected in varying degrees. However, medication errors made by healthcare professionals are usually unexpected and may be associated with serious, potentially life-threatening health-related consequences.

Case in point: the Food and Drug Administration (FDA), Ortho-McNeil Neurolgics Inc. and AstraZeneca just issued a letter to healthcare professionals alerting them of recent reports of medication errors involving Toprol-XL (a beta blocker used to treat hypertension, angina pectoris and heart failure) and Topamax (used to treat epilepsy and migraines). There have also been reports of medication errors involving Toprol –XL and Tegretol or Tegretol-XR, used to treat complex partial seizures, generalized tonic-clonic seizures, and trigeminal neuralgia.

According to the FDA, the medication error reports “include verbal and written prescriptions which were incorrectly interpreted and/or filled due to the similarity in names between Toprol-XL, Topamax, Tegretol, and Tegretol-XR.” In addition, the FDA notes that overlapping strengths between Toprol-XL and Topamax and between Toprol-XL, Tegretol and Tegretol-XR may have also contributed to causing these errors. The letter further states that some cases, medication errors resulted in adverse events leading to hospitalization.

Similar occurrences have occurred in the past with other similar sounding names, such as Lamasil (a drug used to treat fungal infections) and Lamictal, a drug used in the treatment of seizures and bipolar disorder.

When asked how healthcare professionals can make these errors, Carol Holmquist, R.Ph., Director, Division of Medication Errors and Technical Support, Office of Drug Safety, replied, “Medication errors like these are not the result of one person’s incompetence, but are generally system related. Additionally, the names are similar in appearance when scripted, both names begin with the same first 3 letters (top) and end in the letter 'X'. , have overlapping strengths (25 mg, 50 mg, 100 mg, 200 mg), dosage form, route of administration, patient and prescriber population, and use similar drug short code names in the computer. If the drugs are stored alphabetically by trade name on the pharmacy shelf, they may appear in close proximity. Both products appear in white bottles with white labels and the layout labels appear similar. Product similarities such as these increase the risk of computer and product selection errors.”

What Should Be Done to Avoid this Confusion?

To avoid medication errors, the FDA urges physicians to legibly print prescriptions that include both the brand and generic names with indication, and to discuss the indications and proper use of the medications they prescribe with their patients. Pharmacists are advised to arrange products with similar names, labels and strengths on different shelves as well as read labels several times before dispensing to the patient. Holmquist noted that “pharmacies may also consider installing alerts into computer system to further prevent medication errors from occurring.” Pharmacists are also encouraged to communicate with their patients. “The chances of these types of errors occurring would be significantly diminished if the pharmacist and patient discussed both the intended use, and expected therapeutic outcomes of every new prescription”, said Barry E. Gidal, PharmD, Professor of Pharmacy & Neurology, University of Wisconsin.

What Should Patients Do?

“Patients should be made aware of these errors and advised to check and make sure they are receiving the correct medication before leaving the pharmacy. They should know why they are taking their medication and what their medication should look like,” said Holmquist. Patients also need to know that it is not only acceptable, but necessary, that they ask questions when receiving a new prescription, or even a refill, if something about the appearance of the pills, capsules or liquid in the refill seems different than previous refills.

For information regarding your particular anti-epileptic medication go to:

• www.epilepsy.com/epilepsy/seizure_medicinces.html

For information regarding these recent medication errors go to:

• href="http://www.fda.gov/medwatch/safety/2005/toprol_dhcp.pdf" target="new">www.fda.gov/medwatch/safety/2005/toprol_dhcp.pdf