Abstract
P
Case
Ensure that all staff are aware of changes in drug names
The above prescription was written by a physician for an 80-year-old patient. The brand name Unidet is no longer used, as the manufacturer has changed the name to Detrol LA. Unlike Detrol LA, Unidet did not have a suffix. As a result, the dispensing pharmacist was not aware that Unidet was the extended-release formulation of tolterodine L-tartrate. The pharmacist therefore substituted Detrol instead of Detrol LA. The patient took Detrol for one full year until her next visit to the doctor. Upon reviewing the patient's medication, the physician discovered the error.
Possible contributing factors
The name Unidet did not include a suffix that would indicate it was an extended-release product.
The physician prescribed Unidet instead of Detrol LA. The pharmacist was therefore required to make an appropriate substitution.
Both Detrol and Detrol LA are available in the 2 mg strength.
Recommendations
Ensure that all staff are aware of changes in drug names.
When you need to make a substitution, always consult an appropriate reference or contact your drug information centre to confirm that you've made the correct decision.
When dispensing medications, always check the dosing interval for appropriateness.
Review the patient's medication history to detect any change in drug therapy.
Suggest to your software vendor that “alert flags” be used to assist in identifying changes in drug therapy and dose.
Encourage patients to discuss any changes in appearance of their medication.