CASE REPORT Look-Alike Medications: A Formula for Possible Morbidity and Mortality in the Long-Term Care Facility Grant Walliser, PharmD, Richard Grossberg, MD, and Michael D. Reed, PharmD Medication errors remain an important cause of pa- tient morbidity and mortality. Although all medica- tions have the potential to induce unwanted adverse effects, data on the actual incidence and overall sever- ity of preventable adverse drug reactions remains un- known. An Institute of Medicine report (Institute of Medicine. Preventing medication errors: Quality chasm series. Washington DC, National Academies Press. 2007-06-15) estimated that 1.5 million prevent- able adverse drug events occur annually in the US and that from 44,000 to 98,000 individuals die in hospitals annually from preventable medication errors. The types of medication errors of clinical relevance leading to moderate to severe outcomes are unfortunately nu- merous. Such errors would include wrong drug, wrong dose / wrong dose interval and represent the more serious form of a medication error. Institutionalized patients and those patients cared for in long-term care facilities appear to be at heightened risk for a medica- tion error. These patients often receive multiple med- ications and suffer from variable degrees of cognitive impairment which complicates or negates patient- caregiver communication, one of the most important means to prevent medication errors. Moreover, the increasing financial constraints placed upon treat- ment facilities encourage the use of generic, rather than name brand medications by their pharmacy pro- vider. While the use of bioequivalent generic medica- tions is completely appropriate and can be very cost- effective, generic drug manufacturers are less often manufacturing their generic medications to look like the name brand drug. Rather, more and more generic medications are plain appearing with no resemblance whatsoever to the name brand product. This differ- ence in drug appearance between the generic and the brand name product as well as differences in drug appearance between different generic drug manufac- turers for the same medication represents another, important means by which patients may experience moderate to serious consequences from a medication error. We report such an experience where a patient in a long-term care facility received multi-day, excessive dosing of glipizide rather than her anti-spasticity med- ication, baclofen. (J Am Med Dir Assoc 2007; 8: 541–542) CASE REPORT A 48-year-old white female, weighing approximately 36 Kg, with profound mental retardation and spastic quadriplegia following hypoxic ischemic encephalopathy at birth suffers from multiple contractures, seizures, gastroesophageal reflux disease (GERD), reactive airways disease, osteoporosis, and severe scoliosis and receives her medications and nutrients via a g-tube. Following a routine evaluation by her physician it was determined that her spasticity was worsening. Her oral baclofen dose was increased from 10 mg 3 times daily to 15 mg 3 times daily, ie, 1.5 10-mg baclofen tablets per dose per g-tube. All other medications remained unchanged and no possible or probable drug-drug interactions were identified in her medication profile. The patient initially tolerated the increase in baclofen dose well. Although this patient had a history of volume-dependent emesis, these episodes had diminished when switched to a continual feeding pump program experiencing, on average, 1 emesis daily. However, on the third day of her increased baclofen dosing, she experienced 4 emeses episodes in the evening, 4 emesis episodes throughout the fourth day, and 2 emesis episodes on the fifth day. Physical assessment on these Hattie Larlham Center for Children with Disabilities, Hattie Larlham Research Institute and the Division of Clinical Pharmacology (G.W., R.G., M.D.R.) and Toxicology and Clinical Research Center, Children’s Hospital Medical Center of Akron, Mantua and Akron, Ohio (M.D.R.). Address correspondence to Michael D. Reed, PharmD, FCCP, FCP, Clinical Phar- macology and Toxicology Division, Akron Children’s Hospital, One Perkins Square, Akron, Ohio 44308-1062. E-mail: mreed@chmca.org Copyright ©2007 American Medical Directors Association DOI: 10.1016/j.jamda.2007.07.004 CASE REPORT Walliser et al. 541