safe Protect Yourself from Medication Errors

Medicine
Volume 5 Issue 1 www.ismp.org January/February 2007

Ear drops in eyes: A painful mistake Check it out!

Medicines labeled otic are for ears, also chosen non-prescription otic (ear) To avoid mix-ups between eye drops
not eyes. If you accidentally put ear drops when they intended to pur- and ear drops, consider the following:
drops into your eyes, you will quickly chase optic (eye) drops.
know that something is very wrong. 3 Keep in box. Keep your eye drops
Your eyes will burn and sting right Many ear medicines use an eye- and ear drops in
away, and later you might notice dropper (small glass or plastic tube their original car-
redness, swelling, and blurred vision. with a rubber bulb at the top that is tons, as pictures
In most cases, the injury to the eyes squeezed to draw liquid medicine into of an eye or ear
is temporary, but visual changes are the tube), which can subconsciously are often on the
always a real possibility if something lead you to believe the medicine boxes (see figure) but not on the bottles.
irritating gets in the eyes. should be placed in the eyes.
3 Separate drops. Do not store your
Unfortunately, putting ear drops into Sometimes, eye drops can be safely eye drops and ear drops in the same
eyes is a fairly common mistake for used as ear drops because there are location. Also keep pet medicines away
several reasons: relatively few medicines for ears. from human medicines.
However, ear drops should never be
Bottles of ear drops and eye drops used in the eyes. Eye tissue is much 3 Different times. Use your ear drops
can look alike and may be located more sensitive than ear tissue. Thus, at a different time than eye drops.
right next to each other in pharmacies eye drops are specially made to be
and where you store your medicines. gentle and germ-free, yet effective. 3 Use saline drops. To reduce the risk
of harmful mix-ups, try using water and
The medical terms used for ears In your home, ear drops that are used saline ear drops to remove earwax
(otic) and eyes (optic) are very similar. to clear wax out of the ears are most instead of stronger substances that
Pharmacists have sometimes mixed often confused with eye drops. contain carbamide peroxide.
up these terms and labeled prescrip- However, mix-ups between other types
tion ear drops to be put in the eyes. of ear drops and eye drops have been 3 Discard leftover drops. Once you
Otic and optic (or ophthalmic) are reported. We even have a reported have used prescription ear (and eye)
also listed on the outer cartons of case in which ear drops for a pet were drops for as long as the doctor told you,
some bottles of eye drops and ear accidentally put into the eyes of the discard leftover drops. Write the date you
drops. Doctors, pharmacists, and pet owner's child. See Check it out! to open any non-prescription drops on the
nurses have mistakenly picked up a the right for ways that you can avoid label and throw the bottle away 4 weeks
bottle of otic (ear) drops, believing it making this common mistake. later, as it may contain bacteria by then.
was optic (eye) drops. People have
3 Confirm medicine. Take a “time out”
60-second safety tip
before using eye drops to confirm that the
Cold and pain medicines look alike. Parents have reported mix-ups between correct bottle is in your hand. Reading the
two popular over-the-counter liquid medicines for children: label out loud helps prevent mistakes.
3 "pedia relief," a medicine for cold symptoms that contains chlorpheniramine
(an antihistamine for sneezing, runny nose, watery eyes), dextromethorphan (for 3 Flush eyes. If ear drops are acciden-
coughing), and pseudoephedrine (decongestant for nasal congestion) tally put in the eyes, flush the eyes with
3 "pain reliever," which contains acetaminophen (Tylenol, for pain and fever). water and seek emergency treatment if
Continued on next page improvement is not immediate.

Brand name medicines appear in green; generic medicines appear in red.

 safe
Medicine Page 2 January/February 2007

Use your pre-admission testing appointment to 60-second safety tip

prevent medicine errors
continued from page 1
If you are scheduled in advance for you take each one. If possible, also
surgery or a procedure, you will need bring all your medicine bottles with The names and packaging of these
to go to the hospital for a pre- you for the nurse or doctor to review medicines, both
admission testing appointment. You during your appointment. A legible made by
might need blood tests, a physical list of all the medicines you take is Sunmark, look
exam, and instructions about what also important because some drug very similar (see
to do before the procedure. This is a names are very hard to pronounce. the photo). Both
great time to go over your current Simply mispronouncing a drug name medicines also
list of medicines with the nurse or has led to mistakes. come in four-
doctor. Some medicines need to be ounce bottles and the same size
stopped several days or even a week In one case, a woman mispro- boxes. It would be easy to pick up
before the surgery or procedure. nounced the medicine she took for the wrong medicine unless you
This includes over-the-counter osteoporosis, Actonel (rrisedronate), read the label carefully. If you
medicines like aspirin and herbal placing the emphasis on the middle purchase either medicine, be sure
products (e.g., garlic, ginger, ginseng, part of the name (ac-ton'-nel). The you have the correct product.
gingko). If you are admitted to the medicine was misunderstood as the
hospital after your surgery or heart and blood pressure medicine, Public Health Advisory:
procedure, your doctor may need to atenolol (T
Tenormin), which is Migraine medicines and
prescribe these medicines for you pronounced as "a-ten'-a-lul." In antidepressants
during your stay. another instance, Plavix (cclopidogrel) Late in 2006, the Food and Drug
was misheard as Paxil (p paroxetine). Administration (FDA) updated a Public
Since there are many medicines Plavix slows blood clotting and Paxil Health Advisory that had been issued
with names that look and sound is used to treat depression. This mix- about taking certain medicines for
alike, you should bring a neatly up could cause problems since migraine headaches with certain types of
printed or typed list of your Plavix may need to be stopped antidepressants. The medicines involved
medicines with you when you go for before surgery. are listed in Table I (bottom left). Both
your pre-admission testing types of medicine increase the amount of
appointment. Carefully check each Accurate communication about your serotonin in the brain. Serotonin is a chem-
prescription bottle or medicine label medicines with nurses and doctors ical that improves mood and also reduces
to make sure you have spelled the before surgery can boost your safety pain. Taking these migraine medicines and
drug names properly. Include the and help to avoid serious mistakes. antidepressants together can lead to too
dose of the medicines and how often much serotonin in the brain, risking a life-
threatening condition called serotonin syn-
Table 1. Migraine medicines and antidepressants that should not be taken together.
drome. Some consumers have had symp-
Medicines for depression that increase Medicines for migraines that increase toms of restlessness, hallucinations, loss of
serotonin in the brain (improves mood) serotonin in the brain (reduces pain) coordination, fast heart beats, sudden
Celexa (citalopram) Amerge (naratriptan) changes in blood pressure, increased body
fluvoxamine Axert (almotriptan) temperature, nausea, vomiting, and diar-
Lexapro (escitalopram) Frova (frovatriptan)
Paxil (paroxetine) Imitrex (sumatriptan) rhea. If you are taking any of the medicines
Prozac (fluoxetine) Maxalt and Maxalt-MLT (rizatriptan) in Table 1 together, let your doctor know
Symbyax (olanzapine/fluoxetine) Relpax (eletriptan)
Zoloft (sertraline) Zomig and Zomig-ZMT (zolmitriptan) right away. Visit the FDA website at:
Cymbalta (duloxetine) www.fda.gov/ cder/drug/advisory/SSRI_SS
Effexor (venlafaxine) 200607.htm for more information on this
*Meridia, a medicine approved for weight loss but not depression, also increases serotonin in Public Health Advisory.
the brain and should be used with caution when taking other medicines that increase serotonin.
Contact Information
Safe Medicine (ISSN 1550-6282) ©2007 Institute for Safe Medication Practices (ISMP). Reproduction is prohibited without written permission from ISMP.
Editors: Judy Smetzer, RN, BSN; Charlotte Huber, RN, MSN; Michael R. Cohen, RPh, MS, ScD, Russell Jenkins, MD. ISMP, 1800 Byberry Road, Suite 810,
Huntingdon Valley, PA 19006. Email: consumer@ismp.org. To subscribe, visit: https://www.ismp.org/orderForms/safeMedicineSubscription.asp.

Brand name medicines appear in green; generic medicines appear in red.