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A woman in her second trimester of pregnancy developed premature contractions. Her doctor ordered ritodrine (Yutopar), which decreased them only slightly. So he then ordered progesterone vaginal suppositories. A new pharmacist received the order, obtained some suppositories, and sent them to the unit.
Later, the new pharmacist asked about the use of progesterone in premature labor and mentioned he'd just dispensed some called Prostin E2 Alarmed, the senior pharmacist told him that Prostin E2 is dinoprostone-a prostaglandin used to induce abortion. He quickly called the nursing unit and stopped the nurse from administering a suppository. She'd read the label but assumed Prostin E2 was a brand name for progesterone.
Because progesterone and Prostin E2 have similar names, are both hormones, and are both given intravaginally, they have the potential for being inadvertently interchanged. Obviously, this could have disastrous results.
To prevent such an error, stay alert for drugs with similarsounding names. If you're unfamiliar with a drug or its name doesn't correspond with that on the medication order, look it up in a drug reference and call the pharmacist. Don't administer the drug until you're certain it's the right one.