A Missouri hospital has been sued by the parents of one of its patients after the 8-year old girl received the wrong medication. The girl had been prescribed israpidine but was given risperdal instead.
The girl suffered brain damage and kidney damage and will eventually require a kidney transplant.
"Sound-alike" medications cause the potential for medication errors. This arises from the custom in the medical field of the doctor giving oral orders to the staff which are entered in written record later, sometimes without close inspection. The oral orders are then sometimes called into the pharmacy, resulting in further potential for error.
The potential for error engendered by sound-alike medications is well recognzied in the pharmacy field, and should trigger protocols to ensure that only the right medication is dispensed. Many times, when the "wrong" medication is ordered at its normal dose, it is outside the normal therapeutic range for that medication's normal use. Also, it is inappropriate for that diagnosis, even with so-called "off-label" uses. All of these things should trigger a call from the pharamcy to the doctor to ensure that the proper medication is dispensed.
Sound alike medication errors such as this should be prevented through the regular use of protocols designed to ensure the safety of patients.
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