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SafeMedicationUse Newsletter

Consumer Catches Error Involving Similar Medicine Names

2012-05-01 has received a report from a consumer who identified a mistake involving two similar medicine names. This consumer had been treated for an autoimmune disease, a type of disease that can occur when a person's immune system attacks normal body cells. Following a hospital stay of several weeks, the consumer was sent home with a prescription for the medicine cyclophosphamide. Once at home, the consumer noticed that the medicine dispensed by the pharmacy was labeled "cyclosporine". Fortunately, the consumer realized that the wrong drug had been dispensed and did not take the cyclosporine.

Cyclophosphamide and cyclosporine are two different medicines that are used for different reasons. Cyclophosphamide is commonly used to treat some forms of cancer and certain autoimmune diseases. Cyclosporine is commonly used to help prevent organ rejection in people who have had an organ transplant. Cyclosporine may also be used to treat certain autoimmune diseases, but for people with this type of condition, the two medicines are not interchangeable.

Similarities in the appearance of generic or brand names of medicines can cause confusion. In the example described here, the drug names cyclophosphamide and cyclosporine both begin with "cyclo". In addition, these two medicines are available in dosage forms of the same strength. Sometimes, the names of medicines can sound alike when spoken. Although healthcare providers try to provide consumers with the correct medicine, occasionally factors like these can lead to mistakes.

Consumers can play an important role in preventing these types of mix-ups. Here are some tips:
  • Whenever you get a prescription for a new medicine, review the details with your doctor or healthcare provider. For example, ask about the name of the medicine, the dose of the medicine, what it is used for, and how often to take it.
  • If you cannot read what is written on your prescription, ask your doctor or healthcare provider to print the information for you. This will also help to ensure that the pharmacist can read the information correctly.
  • Before you leave the pharmacy, check that the correct medicine has been dispensed. Listen to the information that the pharmacist tells you about the medicine, and ask the pharmacist any questions you may have about the medicine. Always read any printed information that you receive with your medicine. Let the pharmacist know if any of the information you receive is different from what you expected.
  • Keep a list of all your medicines and how you use them. Take the list with you every time you seek medical care. Show the list of medicines to your healthcare providers, and ask them to help you update the list if they make changes to your medicines.
  • If you are admitted to the hospital, bring an up-to-date list of your medicines and all your medicine bottles. Knowing what medicines you are taking at home can help your healthcare team make sure you get appropriate treatment in the hospital. This review of your medicines involves a process called medication reconciliation. Read more about medication reconciliation.
  • When you are discharged from the hospital, ask a healthcare provider to help update your list of medicines to reflect any changes made during your stay.

For more information on checking your prescription and keeping a list of your medicines, see the medication safety tips.

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