She lay on the hospital bed- grateful to the doctors for having successfully fixed her broken bone. She had just been wheeled from the operating room to the ward and was looking forward to going home a day later. Her post-op orders read- nil by mouth for two hours and 2 litres of intravenous fluids. The surgeon also wanted the staff nurse to add Injection Neurobion (Vitamin B) to the intravenous drip – because he believed that vitamins hasten recovery and promote would healing.
The ward round finished, the surgeon left the ward.
A fortnight ago, the hospital information system had introduced a basic version of computerized prescriber order entry (CPOE) in the hospital. The application was designed for the prescribers who could use it to write orders online. All healthcare workers were encouraged to replace traditional paper prescriptions with the electronic ones, because the electronic system offered several advantages- legible orders, faster order completion, accurate inventory management and automatic billing.
The nurse, trained to generate an electronic prescription, selected the patient on the computer screen, clicked a few buttons and began looking for Injection Neurobion. Unable to find Neurobion in the drop down list, she selected the next option in the alphabetical list that the electronic system generated– Neocuron– thinking that this brand named drug too contained vitamin B.
The patient’s relatives bought the drug from the hospital pharmacy and handed it over to the nurse. She promptly added the drug to the glucose dripping through the patient’s veins and went back to her desk.
A couple of minutes later, the patient started breathing slower and harder. She began feeling sleepy, and had difficulty opening her jaw. Her eyes dropped and her arms and legs went limp. A doctor, passing nearby, noticed that the patient looked dangerously ill.
The patient was rushed into the intensive care unit. Residents and nurses enveloped the patient. The doctors checked her vital signs and listened to her lungs and the heart. They checked her oxygen saturation. The numbers looked bad, but the residents had no clue why the patient was deteriorating so fast.
They did what they thought might work best: they attached oxygen to a face mask and infused intravenous fluids.
The operating surgeon, still in the hospital, rushed in. A resident quickly narrated the chain of events. The surgeon glanced at the patient and asked only one question- “Did she receive any drug in the last hour?” “Yes sir”, the nurse promptly answered. “Get me that injection”- the surgeon’s voice had a sense of urgency. The nurse quickly handed him the empty vial. A quick glance at the vial, and the surgeon’s face turned livid. “How on the earth did my patient receive this injection?”, he yelled. He had every reason to get angry- the label on the vial read pancuronium– a long-acting muscle relaxant used by anaesthetists to relax muscles during anaesthesia. The drug paralyses muscles, including those that we use to breathe.
Pancuronium led to pandemonium. The staff nurse was crestfallen. The residents couldn’t believe their eyes. The Neocuron drip was quickly tuned off. An anaesthetist ran from the operating room and injected drugs that would reverse the effects of Neocuron. Six hours later, the patient, blissfully oblivious of what had transpired, began to feel better. She went home four days later, fully healed.
The error could have been deadly. Were it not for the surgeon, who identified and intercepted the error, the medication could have killed the patient.
Neurobion and Neocuron– the first name was so similar to the other drug name that the ward nurse mistook the former for the later. She was not the only nurse to err- worldwide, more than 300,000 medication errors occur each year because of name mix-ups. Most mix-ups are not even noticed. Many are swept under the carpet.
Why do such mix-ups occur? Several factors account for them. Doctors are gifted with hand-writing that that only a pharmacist can read- or guess. Even electronic prescriptions can go wrong- a doctor might pick up a wrong drug from the auto-complete list or a drop-down menu – we were recently told a story of a patient being prescribed K-Trax (hydroxyzine, an anti-allergy drug) instead of Ke-Trip (amitrytipline, anti-depressant). And today I discovered on the pharmacy shelf another look alike- K-Trip Forte (Trypsin Chymotrypsin combination)! K-Trax vs. Ke-Trip vs. K-Trip forte: it would be interesting how many doctors would correctly recall the right drug. Finally, most pharmacists arrange the drugs alphabetically on the pharmacy when surrounded by a large impatient crowd, can pick up a wrong drug. To err is human; to prescribe and dispense accurately, divine.
The Look Alike Sound Alike drugs can -and do -cause adverse reactions. With over 27,000 registered drug companies in India selling drugs worth Rs. 4000 crore ($ 9 billion) every year, and hundreds of thousands of brand named drugs being aggressively marketed , the potential for error due to confusing drug names is enormous. It is easy to prescribe, dispense or administer a wrong drug- an error that is seldom reported.
Three decades ago, in my final year of medical residency, I saw a woman dying an iatrogenic death – she received two tablet of digoxin thrice a day (a drug that slows the heart rate) instead of diodoquine (a drug, banned subsequently, for treating amebiasis). Reason? The nurse couldn’t make out the doctor’s scrawl on the patient’s care record. Those days, in our intensive care unit, Disopyramide and Dipyridamole – popular drugs used to fix heart problems – were also the cause of frequent confusion. Not too long ago, my residents told me a story of a pregnant woman who received six tablets of Eltroxin (thyroid extract) every day , for a week, instead of Althrocin (Erythromycin, an antibiotic) in our outpatient department.
Tweedledum and Tweedledee – doesn’t the tile of this post appear esoteric? Well, these are proper nouns. The characters come from Lewis Carroll’s novel- Through the Looking Glass. These characters were so similar that it was hard to distinguish them. Drugs can be no different- so often they look and sound so similar that it is difficult not to err. And the error can have disastrous consequences. For a patient, just one small (wrong) step by a doctor can become a giant leap – to the heaven. We, the doctors, should remember this.
For a partial list of Look Alike Sound Alike Drugs, here is a link- from the Clinical Pharmacology Department of KEM Hospital, Mumbai.
The list is only partial- with 30 000 doctors acquiring a MBBS degree every year in our country, the list can run into dozens of pages.
