Prescription Mix-Ups: Antacid Medication Renamed After Being Confused with Cancer Drug

Abbreviations, standard packaging intensifies risk of dangerous drug errors.

March 1, 2010, 10:51 AM

March 5, 2010 — -- A popular antacid medication has been renamed at the request of the Food and Drug Administration, because its original "Kapidex" title was being confused with the prostate cancer drug "Casodex." The move is the beginning of a crack down on a long list of confusing, sound-alike drug names that have resulted in thousands of reports of mix-ups each year.

The FDA said the confusion has resulted in "dispensing errors" since the drug was approved in Jan. 2009.

"Today's near miss, today's medication error that doesn't cause harm to somebody could cause harm to someone tomorrow," said FDA Director of Surveillance and Epidemiology Dr. Gerald Dal Pan.

Pam Stockton of Canton, NC said she has seen the error firsthand. She was supposed to get a prescription of a anti-depressant prescribed as a sleeping aid, Trazodone, for her foster daughter. Instead, the pharmacy gave her something with the same first three letters – Tramadol, a pain killer.

"I called the drug store back and they said, no, that's right, it's Tramadol, 50 milligrams. And I said, please just look at the prescription, I really don't think the doctor ordered a pain medication," said Stockton, who contacted ABC News through the Investigative Tip Line. "And she got back on the phone and she said, you're right. We filled it with the wrong thing."

Ron Freeman, CFO of Ingles Market where Stockton was given the wrong medication, told ABC News, "An error was made and we've taken steps to ensure that it does not recur. Our customer well-being is our top concern and we are glad that the customer checked within a short period of time and that no doses of the wrong medication were consumed."

The problem of wrong medications is also stemming from the use of abbreviations by doctors. For example, "PTU" is sometimes used for a medication to treat thyroid problems and another for leukemia.

The problem intensifies with standardized packaging, such as the many eye medications that come in the same shaped bottles but with vastly different strengths that can be too little or too much.

"You wouldn't be treating the infection," said Allen Vaida of the Institute for Safe Medication Practices. "You could lose your eyesight."

Redesigned Prescription System

Target has now introduced a redesigned, color-coded system called "ClearRx" to help consumers avoid mix-ups, created by a graphic design student after her grandmother took her grandfather's pills. Now, the drug name is more prominent, and the bottle includes a tiny magnifying glass.

"There are a lot of causes of medication errors, and we wanted to try and make this not part of the problem," said Deborah Adler, designer of Target ClearRx.

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