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Reporting a Medication Error

A mix-up involving a vaginal ring

a069d384dea5a245079c87294bb310e9 MOur organization received a report from the Food and Drug Administration (FDA) about a mix-up involving a vaginal ring. The mix-up involved two medications that can both be delivered by a vaginal ring. The medication prescribed was NuvaRing (etonogestrel/ethinyl estradiol) but the doctor actually intended to prescribe Estring (estradiol). Vaginal rings release medicine over an extended period of time by inserting a plastic ring shaped device into the vagina (see photo).


Luckily, the pharmacist that was filling the prescription noticed something that caused him to question the order. The prescription for the NuvaRing directed the patient to insert the ring and remove it in three months, not three weeks like it should be. The pharmacist called the doctor and it was determined that a mix-up between the two rings had occurred. The physician mistakenly prescribed NuvaRing instead of Estring.

Both of these rings contain female hormones, but treat two different conditions. The Estring vaginal ring is prescribed for postmenopausal symptoms, such as moderate to severe vaginal itching, burning and dryness. It is left in the vagina for three months. The NuvaRing is prescribed for birth control and is only left in place for three weeks before being removed and replaced with another ring.

If you are being prescribed a vaginal ring, always confirm the brand and generic name of the medicine you are to receive. Have the doctor write the reason you are taking the medicine on the prescription itself. Lastly, if you are new to the medicine always read the package insert to confirm the medication given to you is for the correct reason.

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