Confusion over drug names leads to advisories

The US Food and Drug Administration and Health Canada have issued advisories warning health care professionals about prescribing errors that have occurred because 2 drugs — Seroquel and Serzone-5HT₂ — have look-alike names (see CMAJ 2003; 168 [5]:598).

In Canada there has been 1 reported dispensing error, which did not produce an adverse event. In the US, 7 dispensing errors and a death have been linked to the 2 drugs. A 25-year-old woman experienced respiratory arrest and died after taking Seroquel in error for 3 days, but no causal relationship was proved.

Seroquel is used to treat schizophrenia, while Serzone treats depression. Adverse events resulting from errors include hallucinations, nausea, vomiting, dizziness and mental deterioration.

Dispensing confusion has been attributed to similarities in strength, dosage and dosing interval, as well as poor physician handwriting and the fact that the 2 drugs are stocked close together in pharmacies.

Dr. Nacia Faure, medical director at Bristol-Myers Squibb Canada, which markets Serzone, advises caution when prescribing either product. “It's important that physicians write really clearly and that pharmacists makes sure they really understand what was written.” — Tim Lai, CMAJ