Error Number 45. Confusing "Colace" with "Tolinase"

A nurse in a doctor's office telephoned a neighborhood pharmacist to order a prescription for the stool softener Colace. The pharmacist filled the prescription and the patient picked it up.

Four days later, the patient called the doctor's office to say she'd stopped taking her medication because it had made her weak and dizzy. She'd looked up the drug name in a consumer's drug reference book, which stated that the drug was for diabetes. But her problem, she told the nurse, was constipation.

The nurse asked the patient to spell the name on the prescription label. It was Tolinase, an oral antidiabetic drug.

The nurse realized immediately what had happened. When she'd read Colace to the pharmacist, he'd heard it as Tolinase. The nurse explained the error to the patient and luckily she had no permanent adverse effects.

Ordering a prescription by telephone is a common practice, but not necessarily a safe one. Whenever possible, the order should be written and presented to the pharmacist in person. But if an order must be given by phone, these guidelines can help ensure that it's filled correctly:

• Always ask the pharmacist to read back the complete order to you, spelling the name of the drug and verifying the dosage.
• Write down the drug's name for the patient and pharmacist. Then, when the drug is picked up it can be checked. The original prescription slip would be best.
• Suggest that the patient buy a consumer guidebook to medications. Encourage him to look up the drugs prescribed for him before he takes them.
• Guide your patients to pharmacies where patient counseling occurs. Then, when the pharmacist says "here's your laxative Colace," the patient will have an immediate opportunity to correct an error since they would expect Tolinase for diabetes.
• Most important, carefully check the name of the drug you're about to give, especially if its name looks or sounds similar to another drug name. Frequently, phenobarbital and pentobarbital are accidentally interchanged because their names look and sound alike and their indications are similar. Also, watch out for other drugs that have similar names and can easily be interchanged. There are thousands of possible combinations, like digoxin and digitoxin and quinine and quinidine