Mix-Ups between Diclectin and Dicetel
This supplement aims to raise awareness of the look-alike/sound-alike pair, Diclectin (a combination of doxylamine succinate and pyridoxine hydrochloride) and Dicetel (pinaverium bromide), and to share prevention and mitigation strategies.
INTRODUCTION
Health Canada recently published an alert1 regarding brand name confusion between Diclectin (doxylamine succinate/pyridoxine hydrochloride)2 and Dicetel (pinaverium bromide).3 ISMP Canada previously shared a report of a medication incident describing this mix-up in 2014,4 and has since received 15 additional incident reports of confusion between Diclectin and Dicetel.* This supplement aims to raise awareness of this look-alike/sound-alike (LASA) pair and share prevention and mitigation strategies, recognizing limited evidence of pinaverium’s safety in pregnancy.5
The 15 reports of medication incidents were submitted to ISMP Canada by community pharmacy teams as either near misses (73%) or causing no harm (27%). More than half of the reports described Dicetel as the intended medication (53.3%), and one-third described Diclectin as the intended medication (33.3%); the directionality of the mix-up was unclear in the remaining incidents (13.3%). Figure 1 depicts the stages of the medication-use process in which the confusion between these brand names was reported.
FIGURE 1. The percentage of incidents reported per stage of the medication-use process. An individual medication incident may involve more than one stage, therefore the sum of percentages exceeds 100%.
TABLE 1. Comparison of Diclectin and Dicetel Products
Despite numerous differences between these products (Table 1), the similarity of their brand names continues to present a risk for errors.
RECOMMENDATIONS
The following recommendations are shared for prescribers, pharmacy teams, and health care software providers/administrators to prevent such LASA mix-ups and potential patient harm.
Prescribers
- Include the brand and generic names of the medication on the prescription.6
- Include the indication for the medication on the prescription.6
Pharmacy Teams
- Store stock bottles of LASA products on different shelves to avoid side-by-side presentation.6
- Engage the patient in a discussion about their medication as a final check at pick-up to ensure that the medication, dose, and directions match the intended indication.6,7
- In this example, given that both of these medications are used for patients experiencing gastrointestinal distress, a detailed discussion would be helpful to identify a potential mix-up.
Health Care Software Providers/Administrators
- Configure the default setting in electronic health systems (e.g., computerized prescriber order entry software, pharmacy dispensing software) to require a minimum of 5 letters before the drop-down menu of medication names appears.6,8
The Canadian Medication Incident Reporting and Prevention System (CMIRPS) is a collaborative pan-Canadian program of Health Canada, the Canadian Institute for Health Information (CIHI), the Institute for Safe Medication Practices Canada (ISMP Canada) and Healthcare Excellence Canada (HEC). The goal of CMIRPS is to reduce and prevent harmful medication incidents in Canada.
Funding support provided by Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.
The Healthcare Insurance Reciprocal of Canada (HIROC) provides support for the bulletin and is a member owned expert provider of professional and general liability coverage and risk management support.
The Institute for Safe Medication Practices Canada (ISMP Canada) is an independent national not-for-profit organization committed to the advancement of medication safety in all healthcare settings. ISMP Canada’s mandate includes analyzing medication incidents, making recommendations for the prevention of harmful medication incidents, and facilitating quality improvement initiatives.
Report Medication Incidents (Including near misses)
Online: ismpcanada.ca/report/
Phone: 1-866-544-7672
ISMP Canada strives to ensure confidentiality and security of information received, and respects the wishes of the reporter as to the level of detail to be included in publications.
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Email: cmirps@ismpcanada.ca
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