June 2004, Volume 34 Number 6 , p 18 - 18
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(6) June 2004 p 18 Flutamide or thalidomide? [MEDICATION ERRORS: VERBAL CHEMO ORDERS]
COHEN, MICHAEL R. RPH, MS, SCD
A pharmacist received a telephone order from an oncologist to start a patient on what he heard as “thalidomide” therapy. Because prescribers and pharmacists must be registered in a restricted program to prescribe and dispense thalidomide, he called the pharmacist who was authorized to dispense it. The second pharmacist soon realized that he'd seen the patient earlier on rounds and the team wanted to start the patient on flutamide, not thalidomide. Both products are used to treat prostate cancer
Although reading back a verbal order after you've written it provides a measure of safety, the drug names in this case sound so much alike that reading back the drug name without spelling ...