Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS
We wish to report an ocular chemical injury caused by inadvertent dispensing and administration of an erectile dysfunction cream (Vitaros) instead of an ocular lubricant (VitA-POS) to highlight this potential source of error. Prescribing errors are common, and medications with similar names/packagin...
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| creator | Edington, Magdalena Connolly, Julie Lockington, David |
| description | We wish to report an ocular chemical injury caused by inadvertent dispensing and administration of an erectile dysfunction cream (Vitaros) instead of an ocular lubricant (VitA-POS) to highlight this potential source of error. Prescribing errors are common, and medications with similar names/packaging increase risk. However, it is unusual in this case that no individual (including the patient, general practitioner or dispensing pharmacist) questioned erectile dysfunction cream being prescribed to a female patient, with ocular application instructions. The patient was treated for a mild ocular chemical injury with topical antibiotics, steroids and lubricants, with good response. However, we believe this to be an important issue to report to enhance awareness and promote safe prescribing skills. |
| doi_str_mv | 10.1136/bcr-2018-227468 |
| format | Article |
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Prescribing errors are common, and medications with similar names/packaging increase risk. However, it is unusual in this case that no individual (including the patient, general practitioner or dispensing pharmacist) questioned erectile dysfunction cream being prescribed to a female patient, with ocular application instructions. The patient was treated for a mild ocular chemical injury with topical antibiotics, steroids and lubricants, with good response. However, we believe this to be an important issue to report to enhance awareness and promote safe prescribing skills.</description><identifier>ISSN: 1757-790X</identifier><identifier>EISSN: 1757-790X</identifier><identifier>DOI: 10.1136/bcr-2018-227468</identifier><identifier>PMID: 30567180</identifier><language>eng</language><publisher>England: BMJ Publishing Group LTD</publisher><subject>Antibiotics ; Case reports ; Diagnosis, Differential ; Dry Eye Syndromes - drug therapy ; Erectile dysfunction ; Eye Burns - diagnosis ; Eye Burns - etiology ; Eyes & eyesight ; Female ; Humans ; Iatrogenesis ; Injuries ; Learning from Errors ; Lubricants & lubrication ; Lubricants - adverse effects ; Medical errors ; Medication Errors ; Ophthalmic Solutions ; Pharmacists ; Prescriptions</subject><ispartof>BMJ case reports, 2018-12, Vol.11 (1), p.bcr-2018-227468</ispartof><rights>BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. 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Published by BMJ. 2018</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-b3718-a38e9a64118e268f07c7774d17bcead3b8918814bd62e751aa3f11d826a272643</citedby><cites>FETCH-LOGICAL-b3718-a38e9a64118e268f07c7774d17bcead3b8918814bd62e751aa3f11d826a272643</cites><orcidid>0000-0002-6905-8396</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6301474/pdf/$$EPDF$$P50$$Gpubmedcentral$$H</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6301474/$$EHTML$$P50$$Gpubmedcentral$$H</linktohtml><link.rule.ids>230,315,728,781,785,886,27928,27929,53795,53797</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30567180$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Edington, Magdalena</creatorcontrib><creatorcontrib>Connolly, Julie</creatorcontrib><creatorcontrib>Lockington, David</creatorcontrib><title>Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS</title><title>BMJ case reports</title><addtitle>BMJ Case Rep</addtitle><description>We wish to report an ocular chemical injury caused by inadvertent dispensing and administration of an erectile dysfunction cream (Vitaros) instead of an ocular lubricant (VitA-POS) to highlight this potential source of error. Prescribing errors are common, and medications with similar names/packaging increase risk. However, it is unusual in this case that no individual (including the patient, general practitioner or dispensing pharmacist) questioned erectile dysfunction cream being prescribed to a female patient, with ocular application instructions. The patient was treated for a mild ocular chemical injury with topical antibiotics, steroids and lubricants, with good response. However, we believe this to be an important issue to report to enhance awareness and promote safe prescribing skills.</description><subject>Antibiotics</subject><subject>Case reports</subject><subject>Diagnosis, Differential</subject><subject>Dry Eye Syndromes - drug therapy</subject><subject>Erectile dysfunction</subject><subject>Eye Burns - diagnosis</subject><subject>Eye Burns - etiology</subject><subject>Eyes & eyesight</subject><subject>Female</subject><subject>Humans</subject><subject>Iatrogenesis</subject><subject>Injuries</subject><subject>Learning from Errors</subject><subject>Lubricants & lubrication</subject><subject>Lubricants - adverse effects</subject><subject>Medical errors</subject><subject>Medication Errors</subject><subject>Ophthalmic Solutions</subject><subject>Pharmacists</subject><subject>Prescriptions</subject><issn>1757-790X</issn><issn>1757-790X</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2018</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><recordid>eNqFkc1LHTEUxYO0qKhrdxJwU4SpuUkmybgoiNgPEBS0pbuQyWSeecwkr8mM8P5783hWrJtmk4_7y-HcexA6BvIZgInz1qaKElAVpZILtYP2Qdaykg35_eHNeQ8d5bwkZTHgirNdtMdILSQoso8Wd8llm3zrwwIPLucYMu5THLEJONp5MAnbRzd6awbsw3JO6wv8y08mxVzupntyaXJhGta483nlQnZdec-TMx2O_Qa9rO5u7w_Rx94M2R297Afo59frh6vv1c3ttx9XlzdVy4qhyjDlGiM4gHJUqJ5IK6XkHcjWFkXWqgaUAt52gjpZgzGsB-gUFYZKKjg7QF-2uqu5HV1ni7VkBr1KfjRpraPx-t9K8I96EZ-0YAS43Ah8ehFI8c_s8qRHn60bBhNcnLOmUDeMUiVoQU_focs4p1DaK1RTqxp4A4U631K2jCwn17-aAaI3OeqSo97kqLc5lh8nb3t45f-mVoCzLdCOy_-qPQPXMaa7</recordid><startdate>20181203</startdate><enddate>20181203</enddate><creator>Edington, Magdalena</creator><creator>Connolly, Julie</creator><creator>Lockington, David</creator><general>BMJ Publishing Group LTD</general><general>BMJ Publishing Group</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7RV</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>BENPR</scope><scope>BTHHO</scope><scope>CCPQU</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M1P</scope><scope>NAPCQ</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope><scope>5PM</scope><orcidid>https://orcid.org/0000-0002-6905-8396</orcidid></search><sort><creationdate>20181203</creationdate><title>Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS</title><author>Edington, Magdalena ; 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Prescribing errors are common, and medications with similar names/packaging increase risk. However, it is unusual in this case that no individual (including the patient, general practitioner or dispensing pharmacist) questioned erectile dysfunction cream being prescribed to a female patient, with ocular application instructions. The patient was treated for a mild ocular chemical injury with topical antibiotics, steroids and lubricants, with good response. However, we believe this to be an important issue to report to enhance awareness and promote safe prescribing skills.</abstract><cop>England</cop><pub>BMJ Publishing Group LTD</pub><pmid>30567180</pmid><doi>10.1136/bcr-2018-227468</doi><orcidid>https://orcid.org/0000-0002-6905-8396</orcidid><oa>free_for_read</oa></addata></record> |
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| source | MEDLINE; EZB-FREE-00999 freely available EZB journals; PubMed Central |
| subjects | Antibiotics Case reports Diagnosis, Differential Dry Eye Syndromes - drug therapy Erectile dysfunction Eye Burns - diagnosis Eye Burns - etiology Eyes & eyesight Female Humans Iatrogenesis Injuries Learning from Errors Lubricants & lubrication Lubricants - adverse effects Medical errors Medication Errors Ophthalmic Solutions Pharmacists Prescriptions |
| title | Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS |
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