Oh dear…
A woman has suffered chemical injuries after she was mistakenly prescribed erectile dysfunction cream for a dry eye condition.
The unnamed patient, from Glasgow, was treated in A&E after she used Vitaros instead of VitA-POS to treat her problem, the British Medical Journal Case Reports said.
A pharmacist misread a woman’s prescription for VitA-POS, a lubricant for severe dry eye and corneal erosions, as Vitaros, a cream for erectile dysfunction.
She suffered chemical injuries which required further treatment with antibiotics, steroids and lubricant. The woman recovered within a few days, although she continues to suffer from corneal erosions.
The BMJ report questioned why no one, pharmacist, GP or patient, queried the prescription.
Dr Magdalena Edington wrote in the BMJ report: “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.”
The report stated that further prescription errors like this could be prevented in the future if doctors use capital letters and hyphens for meds like VitA-POS instead of lowercase letters.
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