ISMP MEDICATION SAFETY ALERT, the newsletter of the Institute for Safe Medication Practices (ISMP), warns health professionals that poorly written orders for the oral diabetes medication Avandia (rosiglitazone) can look like Coumadin (warfarin). Both drugs are available in 4mg oral tablets, increasing the likelihood of a mix-up.
The newsletter reports of specific mix-ups, and details one case where the pharmacist first misread the prescription, and then, inspecting the document, realized Coumadin would be inappropriate to this patient. As misdosage with either medication could cause grave danger to a patient, ISMP suggests that all prescription orders should include the medication's purpose. Also, nurses and pharmacists must clarify the drug's purpose prior to dispensing the medication.
For further information, contact: ISMP, telephone: 1- 800-324-5723; e-mail: ismpinfo@ismp.org
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