South Dakota News: Medication Mix-ups

July 1, 2006 4:53 PM Topics: Medication errors

Published in the July 2006 South Dakota State Board of Pharmacy Newsletter

Your assistance is requested in helping to avoid dispensing errors. The following products – Topamax®, Tegretol®-XR, Tegretol, and Toprol-XL® – have been involved in medication mix-ups:

• Toprol-XL (metoprolol succinate) has a boxed warning against abrupt cessation of therapy in patients with ischemic heart disease as it may precipitate angina or myocardial infarction.
• Tegretol has a boxed warning regarding aplastic anemia and agranulocytosis.
• Topamax, Tegretol-XR, and Tegretol have a warning that, as with all antiepileptic drugs, they should be withdrawn gradually to prevent the potential of seizures. 

Your assistance is requested by the manufacturers of these drugs to help avoid future dispensing errors. Steps you can take to decrease potential errors include:

1. Review and provide ongoing training about accepted standards of practice related to accurate medication administration with all staff members.
2. Arrange product inventory to help differentiate medications from one another, especially for products with similar looking labels, names, and strengths.
3. Read labels several times to confirm appropriate product is being dispensed.
4. Be sure a pharmacist reviews all prescription orders entered into the computer and before being dispensed.
5. Counseling your patient is the final check and will prevent errors from leaving the pharmacy if missed during preparation.

Report medication errors to FDA’s MedWatch program at www.fda.gov/medwatch.