A woman in Glasgow, Scotland, had her medicine changed after going to the pharmacy, according to a report published in BMJ Case Reports .
The patient, who did not have her name revealed, was looking for a drug to treat dry eyes and recurrent corneal lesions, but ended up leaving the establishment with an erectile dysfunction ointment .
The error would have happened because of the similar names of the remedy. In the prescription prescribed by the doctor was the name of the VitA-POS eye ointment, and the person who attended it sold the Vitaros erection cream.
Another suspicion, according to the journal, is that the pharmacist did not understand the doctor’s handwriting.
After applying the cream to the eyes, the woman immediately started to experience the first symptoms. Pain in the area, blurred vision, redness and swelling in the eyelid forced her to see a doctor.
In the final balance, the report from the hospital where the patient was seen informed that she was treated with antibiotic eye drops , steroids and lubricants.
The chemical eye damage caused by the use of the changed medication healed in a few days, but the woman continued with the old corneal problem, for which she received treatment and follow-up.
How to avoid prescription and dispensing errors
The most curious thing about this case was that neither the patient nor the pharmacist questioned the use of the erectile dysfunction cream with application guidelines in the eyes, and in someone female.
Drug changes at the pharmacy are not common, but unfortunately it is something that can happen, as the pharmacist Francielle Mathias says.
According to her, pharmacies are looking for ways to avoid this as much as possible, but the correct thing would be for all package inserts to be digitalized, and that this advance is not yet a reality in Brazil.
In case of doubts from the attendant or pharmacist, the correct thing is to contact the doctor to confirm information, such as the name of the medication and dosage.
But if the question is from the patient, it is worth highlighting the importance of reading the package insert before starting to use the medicine, as Mathias points out:
“This would prevent several errors in the way of taking or using the medication, simply because the person is properly informed.”
Currently, there are tools that provide consultation of package inserts online. Sites such as Consulta Remédios have clear and direct information to patients, to facilitate treatment. Be sure to read the package insert!