Woman Gets Erectile Dysfunction Cream For Dry Eye Condition, Pharmacist Bungled Prescription

A woman from Glasgow, Scotland, suffered chemical injuries after she was mistakenly given erectile dysfunction cream for a dry eye condition, a recent case report in the medical journal the BMJ revealed. The unnamed patient was treated at the emergency department of a hospital in Glasgow after she used Vitaros, a topical cream to treat erectile dysfunction, instead of VitA-POS to treat her problem.

She suffered an ocular chemical injury — which included eye pain, blurred vision, redness and a swollen eyelid, according to the BBC. She was supposed to use VitA-POS, an eye ointment used to treat dry eyes and corneal erosions. The mix-up happened between her general practitioner and pharmacist, BBC reported.

The mix-up caused the woman to seek treatment for a “mild ocular chemical injury,” the report said. She was later treated with “topical antibiotics, steroids and lubricants with good response” after she suffered blurred vision and lid swelling as a result of using the wrong cream.

The Tennent Institute of Ophthalmology in Glasgow called on doctors to take greater care issuing medication as a result of the error. It is believed that the pharmacist likely misread the doctor's handwriting in the prescription. It is advised that if an electronic prescription is not used, doctors should ensure handwritten ones “are printed in block capital letters (including the hyphen with VitA-POS) to avoid similar scenarios in the future,” according to BBC.

Dr. Magdalena Edington wrote in the BMJ report: "Prescribing errors are common, and medications with similar names/packaging increase risk... However, it is unusual in this case that no individual (including the patient, general practitioner or dispensing pharmacist) questioned erectile dysfunction cream being prescribed to a female patient, with ocular application instructions."

A 2009 study published in the British Journal of Clinical Pharmacology found that prescription errors accounted for “70 [percent] of medication errors that could potentially result in adverse effects.”

"Any step in the prescribing process can generate errors. Slips, lapses, or mistakes are sources of errors, as in unintended omissions in the transcription of drugs. Faults in dose selection, omitted transcription, and poor handwriting are common," the study found. "Inaccuracy in writing and poor legibility of handwriting, the use of abbreviations or incomplete writing of a prescription, for example by omitting the total volume of solvent and duration of a drug infusion, can lead to misinterpretation by healthcare personnel."