A patient was prescribed VitA-POS to treat her dry eye. But she left the pharmacy with Vitaros, a cream for erection problems.
There is only one letter of difference, and yet … The Vita-POS, consisting of lubricating paraffin and used in the treatment of erosions of the cornea, has nothing to do with the Vitaros, prescribed to men suffering from erectile dysfunction. This minimal difference has nevertheless caused a lot of trouble for a Scot, who has left her pharmacy with Vitaros, which she has applied to her eyes. His general practitioner had indeed provided him with a handwritten prescription of Vita-POS – which one can hardly imagine – hence, perhaps, the confusion of the pharmacist. This unique case has been reported in the BMJ Case Reports last December.
After the application, the patient's vision became confused, then her eyelids blushed and swollen. She then took her eyes under the water, and went to the emergency room. The Scot had actually developed a conjunctival injection, an inflammation of the anterior chamber and a slight epithelial defect. The patient was prescribed topical antibiotics, steroids and lubricant. If the chemical wound disappeared in a few days, the patient continued to suffer corneal erosions for a while.
"The boxes of Vitaros and VitA-POS are different, but someone who has never used Vitaros may have trouble differentiating themthe authors of the paper say, but they are surprised to see that neither the doctor nor the pharmacist nor the patient has realized anything.
For them, it is necessary to review the composition of the Vitaros tube, so that it is more difficult to expel the content. Because unlike tubes of products for the eyes, which release only a few drops, a tube of Vitaros expels a lot of cream. The patient has therefore applied a large amount to the eyes. Fortunately, she is now a business builder, but the situation could have been much worse. Another recommendation of the authors: better write prescriptions. "Prescribers are encouraged to ensure that hand written prescriptions are printed in capital letters, respecting dashes, to avoid such scenarios in the future.", they conclude.