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November 5, 1997

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

Author Affiliations

Southern Illinois University School of Medicine Springfield

JAMA. 1997;278(17):1405. doi:10.1001/jama.1997.03550170035026

To the Editor.  —Pharmaceutical brand name confusion is an important problem.1 We have encountered an example of such confusion when an order for a "Z-Pak" was misinterpreted as an order for an "ice pack."Zithromax capsules of azithromycin are available as red, opaque, hard-gelatin capsules prepackaged in a blister card of 6 capsules, which is called a "Z- Pak." The "Z-Pak" card includes standard dosing instructions for the patient, which allows physicians to write a prescription for the drug by simply writing the term "Z- Pak" on the prescription form without including specific dosing instructions. This abbreviated ordering method resulted in the following therapeutic misadventure.A 49-year-old woman was admitted with new onset of pleuritic chest pain and purulent sputum and had a new infiltrate apparent on the chest x-ray film. An order was written in the hospital inpatient chart for a "Z-Pak." The order included no specific dosing instructions

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