Kasus Sound Alike Drug

A 43-year-old woman was admitted to the intensive care unit for

symptoms of heart and respiratory failure. She was found to have
severe mitral and tricuspid valve regurgitation. She responded
well to medical therapy, and surgical valve repair was scheduled.
During her initial evaluation, a jaw fracture was incidentally
noted. Given the jaw fracture and her valvular disease, an
oromaxillofacial surgeon recommended prophylactic antibiotic
coverage prior to surgery. Penicillin, 500 mg orally four times
daily, was ordered. On the second day of antibiotics, when the
nurse compared the drug with the medication administration
record (MAR), she noticed that the patient was receiving
penicillamine (a non-antibiotic medication used in the
treatment of Wilsons disease and severe rheumatoid arthritis)
instead of penicillin and alerted the pharmacy.
A pharmacist reviewed the original handwritten order and saw
that penicillin was clearly prescribed. The pharmacist who
entered the order into the pharmacy computer system had typed
in the code PENIC and had received a drop-down box that
displayed all formulations and dosages of both penicillin and
penicillamine. That pharmacist had incorrectly selected
penicillamine as the drug to be given. The final check of the
medication (at the time the drug left the pharmacy) compared
the drug product against the information in the pharmacy
computer system but not against the original handwritten order.
The patient suffered no ill effects from the error and received the
course of penicillin as originally prescribed.
http://www.webmm.ahrq.gov/case.aspx?caseID=136

Terjemahan
Seorang wanita 43 tahun dirawat di Intensive Care Unit (ICU)
untuk gejala jantung dan gagal pernapasan. Dia diketahui
memiliki severe mitral dan tricuspid valve regurgitation. Dia

merespon dengan baik terhadap terapi medis, dan bedah

perbaikan katup dijadwalkan. Selama evaluasi awalnya, patah
tulang rahang itu kebetulan dicatat. Mengingat fraktur rahang
dan penyakit katupnya, seorang ahli bedah oromaxillofacial
merekomendasikan antibiotik profilaksis sebelum operasi.
Penisilin, 500 mg per oral empat kali sehari, dimintakan. Pada
hari kedua antibiotik, ketika perawat membandingkan obat
dengan catatan pemberian obat (MAR), ia melihat bahwa pasien
menerima Penisilamin (obat non-antibiotik yang digunakan
dalam pengobatan penyakit Wilson dan rheumatoid arthritis
parah) bukan penisilin dan diberitahu kepada apotek.
Seorang apoteker meninjau permintaan tulisan tangan asli dan
melihat bahwa penisilin dengan jelas ditentukan. Apoteker yang
mengentri permintaan ke dalam sistem komputer farmasi telah
mengetik kode "PENIC" dan menerima sebuah kotak drop-down
yang menampilkan semua formulasi dan dosis keduanya,
penisilin dan penisilamin. Apoteker telah salah memilih
penisilamin sebagai obat yang akan diberikan. Pemeriksaan akhir
dari obat (pada saat itu obat meninggalkan apotek)
membandingkan produk obat terhadap informasi dalam sistem
komputer apotek tetapi tidak terhadap permintaan tulisan
tangan asli. Pasien tidak mengalami efek buruk dari kesalahan
itu dan menerima penisilin seperti yang ditentukan sejak awal.

Penisilamin dan penisilin terdaftar sebagai look alike /

sound alike oleh United States Pharmacopeia, bersama
dengan sekitar 1.100 pasang obat lainnya.

Kasus Look Alike / Sound Alike Drug

An infant was born with sluggish respirations. During labor the

infants mother had received meperidine [Demerol, a pain
medication], a narcotic with a half-life of 2.5-4.0 hours in adults
and 12-39 hours in neonates. The physician started resuscitation
and ordered Naloxone [an opiate antagonist]. Shortly after
administration of the medication, the infants condition began to
deteriorate further.
Prompted by the proximity of the deterioration to the
administration of the naloxone the physician checked the
packaging of the drug. The syringe had inadvertently been filled
with Lanoxin [digoxin, a cardiac medication] instead of
naloxone. The packages of both drugs, made by the same
manufacturer, were almost identical. ECG revealed bi-directional
ventricular tachycardia, consistent with digoxin toxicity.
Approximately 1 hour later the infant died. A post-mortem
digoxin level was 17 ng/ml (therapeutic range 0.8 to 2 ng/ml).
http://www.webmm.ahrq.gov/case.aspx?caseID=39

Terjemahan :
Bayi lahir dengan pernapasan lamban. Selama persalinan ibu
bayi telah menerima Meperidine [Demerol, obat nyeri], narkotika
dengan waktu paruh 2,5-4,0 jam pada orang dewasa dan 12-39
jam
pada
neonatus.
Dokter
memulai
resusitasi
dan
memerintahkan Nalokson [antagonis opiat]. Tak lama setelah
pemberian obat, kondisi bayi mulai memburuk lebih lanjut.
Dipicu oleh terkait kondisi memburuk pada pemberian nalokson,
dokter memeriksa kemasan obat. Jarum suntik itu secara tidak
sengaja telah diisi dengan Lanoxin [digoxin, obat jantung] bukan
nalokson. Kemasan kedua obat, dibuat oleh produsen yang sama,
yang hampir identik. ECG menunjukkan takikardia ventrikel bidirectional, sejalan dengan toksisitas digoxin.

Sekitar 1 jam kemudian bayi meninggal. Tingkat digoxin setelah

meninggal adalah 17 ng / ml (kisaran terapeutik 0,8-2 ng / ml).