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What if you went to your local pharmacy expecting to get an antacid medication for your sick stomach and instead got medication to treat prostate cancer? Well, according to the Food and Drug Administration, that has already happened. In fact, the FDA recently asked the makers of a popular antacid medication to change the name of the product from “Kapidex” to something that sounds more distinct from another medication for treating prostate cancer with the name “Casodex”.

The FDA announced that the confusing names of the two products have led to “dispensing errors” since the antacid’s introduction in January 2009. But these two drugs aren’t the only ones creating confusion and subsequently leading to prescription mix-ups. For example, take Pam Stockton of Canton, NC, who went to her local pharmacy expecting to receive a prescription sleeping aid for her foster daughter. Instead, the pharmacy gave her a pain killer—the reason? The two drugs had similar sounding names—that is, as far as they started with the same first three letters. However, when Pam called her pharmacy to complain about the mix-up, they simply told her that there was no error. Thankfully, Pam didn’t give up and asked them to please double-check, at which point they admitted their error.

However, similarly-named drugs aren’t the only reason that drug mix-ups occur. The problem of wrong medications also stems from the use of abbreviations by doctors. Moreover, the problem intensifies with standardized packaging: the packages may all look the same, but may contain vastly different medications with varying levels of strength.

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