Safe medication prescribing and monitoring in the outpatient setting

Fig. 1: Drug substitution errors can occur even when the drug names do not bear obvious similarities. This hastily written prescription for the diabetic medication Avandia (rosiglitazone) resembles Coumadin (warfarin); moreover, both medications are available in 4-mg tablets. Many examples of such confusions have been reported to the US Food and Drug Administration and the Institute for Safe Medication Practices, which provided permission to reproduce this figure from the 2000 July 26th issue of Medication Safety Alert! (available: www.ismp.org/msaarticles/a072600safety.html).