Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, April 9, 1995 TAG: 9504260002
SECTION: NATIONAL/INTERNATIONAL PAGE: A17 EDITION: METRO
SOURCE: THE BOSTON GLOBE
DATELINE: BOSTON LENGTH: Medium
The drug prescribing and dispensing system ``is a fragile chain that is growing more fragile as the number of new products increases, and the time available for safety checks decreases,'' said Michael Cohen, president of the Institute for Safe Medication Practices in Pennsylvania.
In the Children's Hospital incident, a pharmacist who mixed up BuSpar, an antianxiety drug, and busulfan, the generic name for a potentially highly toxic chemotherapy drug, started a chain of errors that led to the latter medication being given to a boy hospitalized for seizures, officials said Thursday.
Busulfan, trade-named Myleran, can cause anemia and other life-threatening conditions. However, Dr. Michael Epstein, executive vice president and chief operating officer at Children's, said Thursday that there is no sign that Jourdann Moore, now 6, of Mystic, Conn., suffered any medical problems as a result of the mix-up.
``The patient's white [blood cell] count stayed normal throughout the rest of his hospitalization,'' said Epstein. ``And to the best of my knowledge, his white count has stayed normal in the subsequent nine months.'' Epstein said the events of last June began when a doctor wrote a prescription for BuSpar and a nurse correctly copied it onto a form that was submitted to the hospital pharmacy.
``The pharmacy was the site where the error was made,'' he said. One reason may have been that BuSpar is not in the hospital's formulary - an index of approved and commonly used drugs - and is rarely prescribed at Children's.
Epstein said the pharmacist should have checked with the physician to verify that BuSpar was what he wanted to order, but did not.
The unnamed pharmacist entered the first three letters, b-u-s, into a computer and the name of the other drug came up. A change of shifts caused further confusion, and ultimately the anticancer drug, which is used in the treatment of leukemia, was given to the boy for five days. Despite his immediate response of vomiting and diarrhea, nurses and doctors did not check on the prescription. Epstein also acknowledged that even when the boy's mother, Janet Moore, questioned the drug - because the pill was different from the BuSpar her son had taken at home - her challenge was dismissed.
``There's no question that in the series of human errors that occurred, this would stand out as another example,' he said.
After five days, a nurse noticed the discrepancy and the family was immediately informed, Epstein said.
In the wake of the incident, the pharmacy computer has been reprogrammed to give an alert whenever a prescription for a chemotherapy drug is entered into it, said Epstein.
Cohen of the Institute for Safe Medication Practices said the extent of the name confusion problem is unknown. But he mentioned a number of drugs that have been involved in mix-ups, including norfloxacin, an antibiotic that doctors often abbreviate as norflox, and Norflex, a muscle relaxant; Levoxine, a thyroid drug, and Lanoxin, a form of digitalis, a heart drug; and Lasix, a diuretic, and Losec, an ulcer drug. Lanoxin has been renamed Levoxyl, and Losec is now named Prilosec.
Memo: ***CORRECTION***