FDA Medical Bulletin * June 1996 * Volume 26 Number 2

MEDICATION ERRORS

The following information represents FDA's effort to provide the medical community with feedback on some of the more significant medication errors being reported through FDA's MEDWATCH program or through reports received from the U.S.P.'s Medication Errors Reporting Program (in cooperation with the Institute for Safe Medication Practices). Medication errors can be a source of significant morbidity and mortality in the health care setting, and FDA encourages voluntary reporting of potential or actual medication errors. All reports are kept strictly confidential.

• Ambien and Amen
• Amiodarone and Amrinone
• Cardene SR and Cardizem SR
• Clonidine and Klonopin
• Cozaar and Zocor
• Feldene and Seldane
• Flutamide and Flumadine*
• Imipenem and Omnipen
• Lodine and Codeine
• Norvasc and Navane (similarity when handwritten)
• Oruvail and Clinoril (similarity when handwritten)
• Prilosec and Prozac
• Retrovir (Zidovudine) and Ritonavir (Norvir)
• Saquinavier (Invirase) and Sinequan (Doxepin)

*FLUMADINE (Rimantadine tablets, 100 mg), indicated in the prophylaxis or treatment of illness caused by various strains of influenza A, has been inadvertently given to several patients instead of EULEXIN (Flutamide Capsules, 125 mg), which is used to treat prostate cancer.

We encourage confirmation of the patient's diagnosis before dispensing the above medications as one means of reducing the potential for a medication misadventure.

• Concentrated Epinephrine Injection
• Esmolol (BREVIBLOC) Injection

REPORT SERIOUS ADVERSE EVENTS AND PRODUCT PROBLEMS TO MEDWATCH
1-800-FDA-1088