United States of America. The ISMP has received several reports of name confusion concerning Flomax (tamsulosin), used for benign prostatic hypertrophy, and Fosamax (alendronic acid), used chiefly in post- menopausal osteoporosis.
In one case a physician wrote an order for “Flomax 1 q.d.”. Poor handwriting prompted the pharmacist to seek clarification through the nursing service and he was informed that the patient had been taking Flomax 0.4 mg daily. By this time the pharmacy was closed for the day, and the evening nurse manager accidentally filled the order with Fosamax 10 mg from the pharmacy, leaving a note for the pharmacist. The pharmacist assumed that the order had been clarified as Fosamax and the error continued for 3 days.
In this case additional issues contributed to the error, as well as name confusion and poor physician handwriting. The order was incomplete - no dose was specified. If the dose of 0.4 mg had been ordered, staff would have been less likely to confuse Flomax with Fosamax. If the pharmacist had obtained clarification directly from the prescriber, the correct drug would most likely have been dispensed before closing, and the nursing supervisor would not have had to dispense the drug.
All drug orders must specify a dose, even if the drug is only available in one strength. Pharmacists must take an active - never passive - role in clarifying drug orders. Indirect communication of pharmacy concerns is an error-prone practice. Basic information about the patient and drug must be considered. An understanding by the nurses and pharmacists that Fosamax is used in post-menopausal osteoporosis in women and Flomax is used for benign prostatic hypertrophy in men would have prevented the error. Also, although not directly causing this error, it is noted that the physician used the abbreviation “q.d” in the drug order which is often misinterpreted as “qid”. The word “daily” should be used instead.
Reference: ISMP Medication Safety Alert! Vol. 3, Issue 13, 1 July 1998.