United States of America. The ISMP recently received copies of newspaper articles reporting two separate incidences where prescriptions for chlorpromazine were accidentally filled with chlorpropamide, leading to the death of one patient. The ISMP recommends that warning labels or reminders should be affixed to the drug containers and storage bins/shelves to alert staff to this potential error.

Reference: ISMP Medication Safety Alert!, Vol. 4, Issue 10, 19 May 1999.