Abstract
Medication errors may involve prescribing, dispensing, preparation and administration of drugs. We report a case in which an administration error occurred due to ambiguous labelling of a commercial drug. Tablets were packed in sets of two tablets per blister with the print on the blister 'Zelitrex 500', making the amount of drug per tablet unclear. A short survey among nurses and pharmacy technicians showed that the majority interpreted the strength of the tablets incorrectly. This case shows that, despite regulations for controlling and accepting labelling before marketing, ambiguous labelling may occur and can lead to medication errors.
Similar content being viewed by others
References
Kohn L, Corrigan J, Donaldson M, editors. To Err Is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine, Washington, DC: National Academy Press, 1999.
Manasse HR. Toward defining and applying a higher standard for medication use in the United States. Am J Health Syst Pharm 1995; 52: 374–8.
Cohen MR, editor. Medication Errors. Washington, DC: American Pharmaceutical Association, 1999; 13.1–13.22.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Guchelaar, HJ., Kalmeijer, M.D. & Jansen, M.E. Medication error due to ambiguous labelling of a commercial product. Pharm World Sci 26, 10–11 (2004). https://doi.org/10.1023/B:PHAR.0000013517.84814.58
Issue Date:
DOI: https://doi.org/10.1023/B:PHAR.0000013517.84814.58