"Look-alike" and "sound-alike" dispensing error

Today, while browsing the internet, I came across an article in the May 29, 2007 issue of the Sunstar Manila* entitled “High court upholds damage suit v. drugstore chain”.

Here is part of that news article:

“… on Nov. 25, 1993, [Sebastian] Baking went to the clinic of Dr. Cesar Sy for a medical checkup. After undergoing an ECG, blood and hematology examinations, the doctor found that Baking's blood sugar and triglycerides were above normal levels, for which he gave two medical prescriptions -- Benalize tablets for his triglycerides and Diamicron for his blood sugar.

"Baking proceeded to Mercury Drug-Alabang branch to buy the prescribed medicines.

"However, the saleslady misread the prescription for Diamicron as a prescription for Dormicum, a potent sleeping tablet, and sold it to Baking, unaware that it was the wrong medicine.

"On the third day of taking Dormicum, Baking figured in a vehicular accident when he fell asleep while driving his car and it collided with another car. He said that he could not remember anything about the collision or felt its impact.

"Suspecting that the tablet he took may have a bearing on his physical and mental state at the time of the collision, Baking returned to Dr. Sy's clinic.”Upon being shown the medicine, the physician was shocked to find that what was sold to him was Dormicum, instead of Diamicron, prompting Baking to file a complaint for damages before the Quezon City RTC.”

Finally, this year, the Supreme Court has ordered Mercury to pay damages to Mr. Baking for the dispensing error “that caused him to fall asleep and figure in a vehicular accident.”

*****

Although the said article was way back in May 2007, I still decided to write the editor to comment:

Here’s what I wrote:

Dear Editor,

I just would like to comment on the article "High court upholds damage suit v. drugstore chain" (May 29, 2007 issue).

It is my opinion that the error in dispensing Dormicum instead of Diamicron is in the first place an error in prescribing the drug by its brand name.

Medication errors due to "sound-alike" and "look-alike drugs" happen and the article did not mention whether the doctor prescribed the drug by its generic name, because if he did, the drug will most likely be dispensed correctly.

This is because the generic name of Diamicron is gliclazide while midazolam is that of Dormicum. (Both generic names are not "sound-alike and "look-alike".)

Under the Generics Act of 1988, drugs prescribed by their brand names only should not be filled. So if, in this case, the drug was prescribed in its brand name (Diamicron) without the doctor writing the generic name (gliclazide), the drug store chain's employee indeed violated the law in the same manner that the doctor violated the same law.

Then I would say that if only the prescriber and drug store chain employee complied with the Generics Act, none of this thing would happen to the patient.

*****

I shared the above article to my colleagues and there were questions that came up in relation to the case:

1. How come the saleslady had access to a regulated drug, such as midazolam? (Pharmacists are the only ones authorized to have access to regulated and restricted drugs. These drugs are kept locked in their storage areas.)

2. Was there a pharmacist at that time? Should he/she be held liable?

3. Was there a dosage strength written on the prescription? If there was, how come she did not doubt the correctness of the drug that she dispensed? (Dormicum is available as 15 mg per tablet while Diamicron is available as 80 mg per tablet.; Diamicron MR is available as 30 mg per tablet)

*****

In the above case, the Supreme Court ruled that “ ’It is generally recognized that the drugstore business is imbued with public interest. The health and safety of the people will be put into jeopardy if drugstore employees will not exercise the highest degree of care and diligence in selling medicines’ ”.

I hope that every pharmacist who reads this learns that we have a social responsibility to guard the public health and by being negligent of our duty to properly dispense drugs, we certainly have a price to pay for our shortcomings. Pharmacy assistants or clerks should never be allowed to do the job that we are licensed to do. Let alone, to dispense a drug without regard to its classification as prescription or OTC drug.


*Source:
http://www.sunstar.com.ph/static/man/2007/05/29/news/high.court.upholds.damage.suit.v..drugstore.chain.html