The consequence of mixing up two medications can be fatal. However, the FDA receives reports of such mistakes happening all the time. These errors often occur because the names of varying medications can be remarkably similar to other medications on the market, resulting in mis-administration of drugs. Pharmacists may not accurately read the prescription name, or may become confused when the similar drug is situated close to another on the shelf. To help remedy this confusion, the FDA launched an initiative in 2001 known as the Name Differentiation Project. This requires drug companies with easily misinterpreted names to add “tall man” lettering to certain syllables of the drug name; for example: MethylPREDNISolone versus MethylTESTOSTERone. While this effort has helped considerably, mistakes still occasionally occur.
- Almarl vs. Amaryl: Confusion between Almarl and Amaryl occurs in Japan almost exclusively, as Almarl is a Japanese drug not available in the United States. The names of the two drugs look similar both in Roman characters and Japanese Katakana characters. Amaryl is used to treat diabetes, while Amarl is administered for treating hypertension. Accidentally
swapping the two drugs has led to deaths of various patients in Japan. These accidents have created greater awareness among medical experts in Japan as to drugs with similar-sounding names. The Ministry of Health, Labor, and Welfare also developed a search engine to look up medications with similar names to avoid further discrepancies.
- Flomax vs. Volmax: Flomax is administered for treatment of the signs and symptoms of benign prostatic hyperplasia, which is when the body builds extra cells in the prostate. Volmax is used to treat bronchospasms, which are spasms that occur in the bronchioles. These two vastly different drugs, however, have cloyingly similar names, causing much confusion in the pharmacy and among its users. Likewise, they come in similar dosage strengths, as where Flomax may be administered in 0.4 mg capsules, Volmax comes in 4 mg tablets; the decimal point may be overlooked. Although most medication mix-ups go unreported, several instances of confusion between these two drugs were catalogued between 1997 and 2000. Of those reports, only one did not detect the error prior to taking the medication. She underwent adverse effects such as a chronic sinus infection and a polyp on her vocal chord, both of which required surgery.
- Serzone vs. Seroquel: There has been noted confusion between Serzone, an antidepressant, and Seroquel, which is used to treat schizophrenia. Not only do they have similar strengths, forms, and dosage intervals, but they are stacked closely together on the shelves at the pharmacy, rendering them easy to confuse with one another. In any case in which the drugs are administered incorrectly, the patient’s state would deteriorate because of the incorrect prescription. Depression symptoms would worsen in patients mistakenly taking Seroquel, while the schizophrenic patients taking Serzone would sink further into symptoms induced by schizophrenia, including delusions, disorganized behavior, and social withdrawnness, among other symptoms. The packages were changed on both drugs to help better differentiate between them and to hopefully avoid further mistakes.
- Kapidex vs. Casodex: While it has now been safely renamed to avoid further confusion, Kapidex (now Dexilant) had a penchant for being confused with Casodex. The problem with confusing these drugs, like any drug mix-up, was their wildly different uses — Kapidex is a popular antacid, while Casodex is used to treat prostate cancer. While Kapidex is sure to get the job done when treating things like heartburn and acid reflux, it would not be interchangeable with a drug that actively treats prostate cancer by lowering male hormones. Kadian, which is by the makers of Casodex, was also being confused with Kapidex, which is particularly troubling as it is a morphine-based pain killer and could easily cause an overdose.
- Durezol vs. Durasal: Durezol, which is given to patients that have recently undergone eye surgery to reduce inflammation, may sound the same phonetically as Durasal, but the two drugs could not be more different. Durasal, by contrast, is used to get rid of warts, and is made of salicylic acid. The FDA has found several cases in which the two drugs were confused with one another. In one instance, the pharmacist gave the patient the wart remover in an eye-drop dispenser thinking it was Durezol, which resulted in serious injury. Imagine trying to soothe your inflamed eye by trickling drops of acid into it. Using the eye drops in place of wart remover will not have serious consequences; however, it is never wise to use a medication outside of its intended use.