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November 5, 1997

'Z-Pak' vs Ice Pack: Need for Clarity and Continuous Quality Assurance-Reply

Author Affiliations

American Medical Association Chicago, Ill

JAMA. 1997;278(17):1405-1406. doi:10.1001/jama.1997.03550170035027

The experience of this patient highlights the types of medication errors that occur even when the right drug is chosen and ordered for a patient. The United States Pharmacopeia Medication Errors Reporting Program, a Food and Drug Administration Med Watch partner, catalogs medication errors, including problems with product names. Their reporting form encourages recommendations to prevent recurrence of the error. Copies of the United States Pharmacopeia Medication Errors Reporting Program report are routinely shared with the Institute for Safe Medication Practices, the manufacturer, and the Food and Drug Administration. In the past, this process has even resulted in the change of brand names. For instance, it was noted that "Losec" (omeprazole) was being confused with "Lasix" (furosemide) and so the brand name was changed to "Prilosec" (omeprazole). Physicians should work with their pharmacy and therapeutics committees to routinely report such occurrences in their hospitals, call United States Pharmacopeia Medication Errors

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