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AIDS Medication Errors

Journal of the American Medical Association
Vol. 278, No. 11, P. 888 (09/17/97)

Confusion regarding similar HIV-drug brand names has resulted in at least 10 prescription errors, according to the Medication Errors Reporting (MER) program. In a recent issue of the USP Quality Review, the MER program, which is operated by the non-profit US Pharmacopeia (USP), said the errors were in reading and copying orders and in filling prescriptions for HIV medication. Most common was confusion between Retrovir, the brand name of zidovudine or AZT, and protease inhibitor ritonavir; and confusion between the anticonvulsant lamotrigine and the antiviral lamivudine. In "Errors With Antivirals Increase Risk to Patients," MER also noted that one patient was sent to intensive care after his prescription for the protease inhibitor saquinavir was filled with the antidepressant Sinequan.

To avoid further confusion, the USP recommends ordering drugs by both brand and generic names; keeping stock of similarly named drugs in separate areas; avoiding abbreviations; and ascertaining the knowledge of patients, practitioners, and staff regarding these drugs.


The CDC National Center for HIV, STD, and TB Prevention makes this information available as a public service only. Providing this information does not constitute endorsement by the CDC. Reproduction of this text is encouraged; however, copies may not be sold, and the CDC National AIDS Clearinghouse should be cited as the source. Copyright 1996, Information, Inc., Bethesda, MD




  
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This article was provided by U.S. Centers for Disease Control and Prevention. Visit the CDC's website to find out more about their activities, publications and services.
 

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