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The Annals of Pharmacotherapy: Vol. 37, No. 1, pp. 87-89. DOI 10.1345/aph.1C217
© 2003 Harvey Whitney Books Company.
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Dispensing Error Leading to Alendronate Ingestion

Benoit Carrière, MD FRCPC

Emergency Pediatrician, Hôpital Sainte-Justine, Montréal, Quebec, Canada

Benoit Bailey, MD MSc FRCPC

Toxicologist/Emergency Pediatrician, Division of Emergency Medicine, Department of Pediatrics, Hôpital Sainte-Justine

Gilles Chabot, MD FRCPC

Pediatrician, Department of Pediatrics, Hôpital Sainte-Justine

Denis Lebel, BPharm MSc

Pharmacist, Department of Pharmacy, Hôpital Sainte-Justine

Reprints: Benoit Carrière MD FRCPC, Hôpital Sainte-Justine, 3175 Chemin Côte Ste-Catherine, Montréal, Quebec H3T 1C5, Canada, FAX 514/345-4823, E-mail bcarriere9{at}hotmail.com

OBJECTIVE: To report a case of medication dispensing error by administration of similarly packaged drugs.

CASE SUMMARY: A 6-year-old East Indian boy with asthma was mistakenly given alendronate, a bisphosphonate, for 3 months instead of montelukast, a leukotriene-receptor antagonist. Symptoms of esophageal irritation developed and disappeared on discontinuation of alendronate.

DISCUSSION: Alendronate and montelukast have very similar packaging and are available in dosages that also can be similar for some patients. Alendronate caused symptoms of irritative gastritis in this child before the error was identified. This case report emphasizes one of the possible sources of medication dispensing errors: a mistaken identification due to similar packaging (confirmation bias). Manufacturers can help to prevent medication errors in many ways; in this case, more distinct packaging would have decreased the risk of error. A standard bar-coding scheme among manufacturers could lead to an important improvement in the safety of medication dispensation. Practitioners are also encouraged to report such errors to the United States Pharmacopoeia Medication Errors Reporting Program.

CONCLUSIONS: With increased awareness of medication errors, healthcare practitioners, manufacturers, and patients should take precautionary steps to prevent dispensing errors and their consequences.

Key Words: alendronate, dispensing error

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