Author's response: You're correct that if the prescriber had used the generic name, the error probably wouldn't have happened. In this case, a physician picked up the error when he looked at a 24-hour medication list update. My hope is that others will read this, know why this step is important, and then educate others or help to implement error prevention strategies, such as a 24-hour review by physicians.

Because of space limitations, we can't discuss every error prevention strategy in every Medication Errors item. For more information, see our list of prevention strategies for name mix-ups at http://www.ismp.org/newsletters/acutecare/articles/20070809.asp, especially the section for organizations, practitioners, and patients.

-MICHAEL R. COHEN, ScD, MS, RPh