title: Medication error due to ambiguous labelling of a commercial product.
abstract: Medication errors may involve prescribing, dispensing, preparation and administration of drugs. We report a case in which an administration error occurred due to ambiguous labelling of a commercial drug. Tablets were packed in sets of two tablets per blister with the print on the blister 'Zelitrex 500', making the amount of drug per tablet unclear. A short survey among nurses and pharmacy technicians showed that the majority interpreted the strength of the tablets incorrectly. This case shows that, despite regulations for controlling and accepting labelling before marketing, ambiguous labelling may occur and can lead to medication errors.
authors.affiliation: Department of Clinical Pharmacy & Toxicology, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands. h.j.guchelaar@lumc.nl
authors.forename: Henk-Jan
authors.initials: HJ
authors.lastname: Guchelaar
authors.forename: Mathijs D
authors.initials: MD
authors.lastname: Kalmeijer
authors.forename: Minke E P
authors.initials: ME
authors.lastname: Jansen
mesh_terms: D000212:Acyclovir / Q000008:administration & dosage* / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000328:Adult; D000998:Antiviral Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D004348:Drug Labeling / Q000379:methods*; D004349:Drug Packaging / Q000379:methods*; D005260:Female; D006562:Herpes Zoster / Q000517:prevention & control; D006801:Humans; D008508:Medication Errors; D000077483:Valacyclovir; D014633:Valine / Q000008:administration & dosage* / Q000031:analogs & derivatives* / Q000627:therapeutic use
chemical_list: D000998:Antiviral Agents; D014633:Valine; D000077483:Valacyclovir; D000212:Acyclovir