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FDA alerts pharmacists to look-alike, sound-alike dangers of two drugs

Pharmacy Regulation Resource, November 10, 2004

A FDA alert highlights the need for caution when handling look-alike and sound-alike drugs, a National Patient Safety Goal that will take effect January 1.

Medication error reports to MedWatch, the FDA error reporting system, included instances where physicians prescribed Reminyl-an Alzheimer's drug-but pharmacists mistook the drug name for the diabetes medication Amaryl and dispensed that instead. The errors included severe hypoglycemia and one death, according to the FDA.

Revisions to National Patient Safety Goal #3 (posted at www.jcaho.org) require you to identify at least annually a list of look-alike and sound-alike drugs used in your organization and prevent errors that may occur by confusing the drugs.

Both products in the FDA alert are in tablet form with a strength of 4 mg, according to a letter to pharmacists from Janssen Pharmaceutica, maker of Reminyl. Their generic names-galantamine for Reminyl and glimepiride for Amaryl-could lead to them being placed close together in the pharmacy stock.

Aventis Pharmaceuticals manufactures Amaryl.

Pharmacists should place Amaryl and Reminyl apart from each other on the shelf and confirm the brand name prescribed when filling an order, according to the letter. Keep the following phone numbers on hand to report any errors:

• 800/526-7736 if Reminyl is involved
• 800/633-1610 if Amaryl is involved

You may also report errors to MedWatch at 800/FDA-1088 or the Institute for Safe Medication Practices at 800/23ERROR. Go to www.fda.gov/medwatch for more information.

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