Rapid Responses to:

FILLERS: Austin G McCormick A medical mishap: Caustic eye drops BMJ 2002; 324: 1314 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Packaging as a cause of errors in drug use

Dan Michaeli   (1 June 2002)

Similarly

baskaran sundaram   (5 June 2002)

Packaging as a cause of errors in drug use 1 June 2002
Dan Michaeli, Chairman , Board of Directors Clalit Health Services 101 Arlozorov st, Tel Aviv 62098, Israel Send response to journal: Re: Packaging as a cause of errors in drug use	A young obstetrician , about 15 years ago was treating a neonate just born to a woman who recieved pethidine during labor. He was giving the baby mouth to mouth respiration and asked the nurse for "naloxone" (opiod antagonist) ,but she gave him "lanoxine" (digitalis lanata)! The child died soon from ventricular flutter. Not only the names were similar but the boxes, the labels and the vials were almost identical. With the increased numbers of generic drugs this kind of mistakes must happen more often. Should we insist that labelling will include the generic names in letters which are more visible than the brand names and manufacturers trade marks ? I believe the WHO and international consumers' organisations should intervene.
Similarly 5 June 2002
baskaran sundaram, SpR radiology Royal hallamshire hospital sheffield S10 Send response to journal: Re: Similarly	Similarly 10 ml plastic ampules of normal saline, water for injection and lignocaine can look identical if we are not careful.