Diabetes Disaster Averted #66: Beware of Similar Names
I work as a staff pharmacist at a community hospital in the Northeast. I received an order via POM for Nevirapine (brand = Viramune) 500 mg po BID. Since Viramune (an anti-retroviral medication) comes at 200 mg strength I decided to look into this order. I could not find any order history of this patient ever receiving this medication nor could I find such an indication for use in this patient....
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The floor nurse showed me the MAR from the nursing home and there it was in black and white: Viramune 500 mg po BID. I decided to call the nursing home.
The nursing home nurse confirmed the patient receives Viramune twice daily after reviewing the patient's MAR. I asked her to get the patient's stored supply and actually read the dose and the pharmacy name. She retrieved the bottle (which she described as a box) and read the labeling. "Viramune 500 mg capsules," she continued, "for use as an immune booster."
That was the answer: this product is an herbal supplement with the same exact name as the anti-retroviral medication Viramune. After searching the internet I did come across ViRamune herbal supplements from a company named Trilight which makes both a liquid and a 500 mg dosage form of their product.
I contacted the doctor to report my findings. The doctor cancelled the order and dictated an addendum to the admission note saying that this patient does not take Viramune.
Lesson Learned:
There are numerous products with similar names. When in doubt check the patients profile for past medications and indications and where possible ask the patient why they are taking the medication.
Donna Ciulla, R.Ph.
Courtesy Institute of Safe Medication Practices (www.ismp.org)
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