The Pharmaceutical Journal
Vol 273 No 7320 p514
9 October 2004

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· Pharmacy education
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Letters to the Editor

Dispensing errors

Similar sounding names that could be dispensed wrongly

From Dr T. U. Qazi, MRPharmS

A patient approached me to find out why, this time, his loperamide tablets had not relieved his diarrhoea. On examination I found he had been given lofepramine instead of loperamide by the pharmacist. The prescription had been telephoned through by the doctor’s receptionist. On a computerised prescription loperamide tablets, lodoxamide eye drops and lofepramine tablets are distinctly different but under busy conditions mistakes can happen. Other similar sounding drugs have been reported to be wrongly dispensed. I have come across a similar incident where Eucerin cream and mupirocin cream were mixed up by a busy pharmacy.

So, possible causes of dispensing errors are doctors who scribble prescriptions and receptionists who are be unable to pronounce drug names correctly. I suggest that if it is not possible to provide a computer-generated prescription, doctors should write neatly. In addition, surgery receptionists should be trained just as staff in a pharmacy are expected to be.

T. U. Qazi
Halifax, West Yorkshire

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