Preventing prescription mix-ups between Prozac and Prilosec


One of the medication errors reported recently to the Institute for Safe Medication Practices (ISMP) through this website involved a patient who dropped off her doctor's prescription for Prilosec (omeprazole), a drug for acid reflux, at a local pharmacy. After she picked up the prescription and got home, she opened the bottle.

The woman, who happened to be a home health worker, immediately recognized that her pills were not Prilosec but instead looked to her like green Prozac (fluoxetine), an antidepressant. She brought the pills back to the pharmacy and it was confirmed that the doctor's poorly handwritten prescription looked like Prozac to the pharmacist who dispensed the wrong drug.

This is actually one of many reports of mix-ups between these two medications. Patients taking prescription Prilosec or Prozac should be aware of the potential for medication errors. The names of these drugs are easily misread when handwritten. This woman was able to prevent a medication error because she was already familiar with the appearance of the medications through her work in home health. Most people would not be so familiar.

To protect yourself from drug name mix-ups in general, not just with the above drug names, one of the selection criteria in choosing a doctor should be whether or not they use computers to prescribe medications. For one, it makes reading prescriptions much easier. For another, it alerts the doctor if something is wrong with the prescription like accidentally prescribing a drug to which you are allergic or prescribing a dose that is too high.

Still, less than 20% of American doctors use computerized prescriptions today, so it's still necessary to know what to do to prevent mix-ups.

Always ask your doctor to put the purpose of the medication on the prescription. In case of poorly handwritten prescriptions, this helps the pharmacist to realize what the medication is supposed to be since the drug and purpose will match. In other words, any pharmacist would recognize that Prozac is NOT for gastric reflux and Prilosec is not an antidepressant.

Prescription errors do not happen very often but the reality is they do occur and you want to be sure to protect yourself and family members. Never leave the pharmacy without asking to have the pharmacist go over your medications with you in a quiet, discreet consultation area. Have the pharmacist open each pill container and show you the contents. This gives each of you a chance to confirm the appearance and match what each drug is for. Do this with both new and refill prescriptions. There are other reasons that error happen besides a pharmacist misreading a doctor's prescription. For example, mix-ups have happened where patient names are confused and a patient gets someone else's medication or the wrong drug is dispensed for other reasons. Patients make a mistake by not speaking to a pharmacist when picking up medications because a good opportunity is lost for confirming the right medication.

Created on June 6, 2011

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