Letters and names: latent conditions for a medication error

Alpujarras, Spain

A patient with a diagnosis of non-hodgkin lymphoma started with a facial herpes  spreading to the right eye. The oncologist prescribed  an oral antiviral drug but something went wrong…Can you suggest the problem?

Valaciclovir was prescribed but it was not available at that moment at the hospital and another doctor was required to solve the situation. Looking at the electronic pharmacological portfolio the doctor found  and selected Valganciclovir thinking that was the same drug, but Valganciclovir has an indication to treat cytomegalovirus infection.




VALTREX                                          Valaciclovir                                                Herpes

FAMVIR                                             Famciclovir                                               Herpes

VALCYTE                                           Valganciclovir                                          Cytomegalovirus



When drug names share common words and also they are used to treat a common group of infectious agents like virus in this case, the situation is prone to error. Clinical indications and toxicity are quite different between compounds putting patients at risk.