October 2004, Volume 34 Number 10 , p 14 - 14
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(10) October 2004 p 14 Nurse saves patient from taking the heat [MEDICATION ERRORS: LOOK-ALIKE NAMES]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
A patient with genital herpes had been applying the antiviral cream acyclovir (Zovirax) to treat it. She was admitted to the hospital for another problem and mistakenly told her primary care provider that she was using Zostrix (capsaicin). He then ordered “Zostrix topically to affected areas three times daily” without specifying the drug's strength. The pharmacy dispensed Zostrix cream, 0.025%, the only strength available at the hospital.
The patient's nurse, who'd used Zostrix herself for arthritis pain—as indicated—thought that applying “hot pepper cream” to the genital ...