Kasus Sound Alike Drug A 43-year-old woman was admitted to the intensive care unit for symptoms of heart and respiratory failure. She was found to have severe mitral and tricuspid valve regurgitation. She responded well to medical therapy, and surgical valve repair was scheduled. During her initial evaluation, a jaw fracture was incidentally noted. Given the jaw fracture and her valvular disease, an oromaxillofacial surgeon recommended prophylactic antibiotic coverage prior to surgery. Penicillin, 500 mg orally four times daily, was ordered. On the second day of antibiotics, when the nurse compared the drug with the medication administration record (MAR), she noticed that the patient was receiving penicillamine (a non-antibiotic medication used in the treatment of Wilsons disease and severe rheumatoid arthritis) instead of penicillin and alerted the pharmacy.A pharmacist reviewed the original handwritten order and saw that penicillin was clearly prescribed. The pharmacist who entered the order into the pharmacy computer system had typed in the code PENIC and had received a drop-down box that displayed all formulations and dosages of both penicillin and penicillamine. That pharmacist had incorrectly selected penicillamine as the drug to be given. The final check of the medication (at the time the drug left the pharmacy) compared the drug product against the information in the pharmacy computer system but not against the original handwritten order. The patient suffered no ill effects from the error and received the course of penicillin as originally prescribed.http://www.webmm.ahrq.gov/case.aspx?caseID=136

TerjemahanSeorang wanita 43 tahun dirawat di Intensive Care Unit (ICU) untuk gejala jantung dan gagal pernapasan. Dia diketahui memiliki severe mitral dan tricuspid valve regurgitation. Dia merespon dengan baik terhadap terapi medis, dan bedah perbaikan katup dijadwalkan. Selama evaluasi awalnya, patah tulang rahang itu kebetulan dicatat. Mengingat fraktur rahang dan penyakit katupnya, seorang ahli bedah oromaxillofacial merekomendasikan antibiotik profilaksis sebelum operasi. Penisilin, 500 mg per oral empat kali sehari, dimintakan. Pada hari kedua antibiotik, ketika perawat membandingkan obat dengan catatan pemberian obat (MAR), ia melihat bahwa pasien menerima Penisilamin (obat non-antibiotik yang digunakan dalam pengobatan penyakit Wilson dan rheumatoid arthritis parah) bukan penisilin dan diberitahu kepada apotek.Seorang apoteker meninjau permintaan tulisan tangan asli dan melihat bahwa penisilin dengan jelas ditentukan. Apoteker yang mengentri permintaan ke dalam sistem komputer farmasi telah mengetik kode "PENIC" dan menerima sebuah kotak drop-down yang menampilkan semua formulasi dan dosis keduanya, penisilin dan penisilamin. Apoteker telah salah memilih penisilamin sebagai obat yang akan diberikan. Pemeriksaan akhir dari obat (pada saat itu obat meninggalkan apotek) membandingkan produk obat terhadap informasi dalam sistem komputer apotek tetapi tidak terhadap permintaan tulisan tangan asli. Pasien tidak mengalami efek buruk dari kesalahan itu dan menerima penisilin seperti yang ditentukan sejak awal.

Penisilamin dan penisilin terdaftar sebagai look alike / sound alike oleh United States Pharmacopeia, bersama dengan sekitar 1.100 pasang obat lainnya.

Kasus Look Alike / Sound Alike Drug

An infant was born with sluggish respirations. During labor the infants mother had received meperidine [Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours in adults and 12-39 hours in neonates. The physician started resuscitation and ordered Naloxone [an opiate antagonist]. Shortly after administration of the medication, the infants condition began to deteriorate further.Prompted by the proximity of the deterioration to the administration of the naloxone the physician checked the packaging of the drug. The syringe had inadvertently been filled with Lanoxin [digoxin, a cardiac medication] instead of naloxone. The packages of both drugs, made by the same manufacturer, were almost identical. ECG revealed bi-directional ventricular tachycardia, consistent with digoxin toxicity.Approximately 1 hour later the infant died. A post-mortem digoxin level was 17 ng/ml (therapeutic range 0.8 to 2 ng/ml).http://www.webmm.ahrq.gov/case.aspx?caseID=39

Terjemahan :Bayi lahir dengan pernapasan lamban. Selama persalinan ibu bayi telah menerima Meperidine [Demerol, obat nyeri], narkotika dengan waktu paruh 2,5-4,0 jam pada orang dewasa dan 12-39 jam pada neonatus. Dokter memulai resusitasi dan memerintahkan Nalokson [antagonis opiat]. Tak lama setelah pemberian obat, kondisi bayi mulai memburuk lebih lanjut.Dipicu oleh terkait kondisi memburuk pada pemberian nalokson, dokter memeriksa kemasan obat. Jarum suntik itu secara tidak sengaja telah diisi dengan Lanoxin [digoxin, obat jantung] bukan nalokson. Kemasan kedua obat, dibuat oleh produsen yang sama, yang hampir identik. ECG menunjukkan takikardia ventrikel bi-directional, sejalan dengan toksisitas digoxin.Sekitar 1 jam kemudian bayi meninggal. Tingkat digoxin setelah meninggal adalah 17 ng / ml (kisaran terapeutik 0,8-2 ng / ml).