A Woman Was Accidentally Given Erectile Dysfunction Cream Instead Of Eye Cream

Prescription errors are common, especially when it comes to medicines with similar names, says an ophthalmologist.

Stock photo of a doctor holding a prescription pad.
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Prescription errors are common, especially when it comes to medicines with similar names, says an ophthalmologist.

A British woman got considerably more than she bargained for when she was accidentally given prescription erectile dysfunction medication — instead of the eye cream she needed to clear up an eye problem.

As BBC News reports, the Scottish woman, whose name has not been released, went to get treatment for a mundane eye issue. The doctor prescribed her VitA-POS, a paraffin-based eye lubricant used to treat dry eyes and corneal erosions.

However, the pharmacist apparently mis-read the prescription, and instead dispensed Vitaros. According to Lloyd’s Pharmacy, Vitaros is a vasodilator cream used to treat erectile dysfunction.

The woman, not knowing any better, put the cream on her eyes. She later wound up in the emergency room — suffering from eye pain, blurred vision, redness, and swollen eyelids. Fortunately, she was treated — correctly this time — with antibiotics, steroids, and lubricants. The “mild chemical injury” cleared up within a week.

There should have been warning signs in this regretful situation says Dr. Magdalena Edington, of Glasgow’s Tennent Institute of Ophthalmology. Dr. Edington questioned why the pharmacist did not stop to wonder why a woman would be prescribed an erectile dysfunction medicine — particularly with express instructions to apply it to her eyes.

Though the Scottish patient made it through the ordeal with no severe injuries, the case highlights a commonplace communication gap between pharmacists and doctors, Dr. Edington says.

“Prescribing errors are common, and medications with similar names and packaging increase risk… We believe this to be an important issue to report, to enhance awareness and promote safe prescribing skills.”

This reality is even culturally reiterated by an old joke and stereotype — that of the doctor with terrible handwriting, leaving nurses, pharmacists, and other practitioners to work to infer meaning from the crude penmanship.

The joke is not funny at all in reality, says Dr. Edington. She suggests that doctors move towards digital orders, as many hospitals have done. Failing that, they should write their prescriptions in block capital letters, taking extra care when it comes to medications with similar names.

The numbers seem to back Dr. Edington up. In the U.K., for example, there were an estimated 237 million prescription errors in 2018 — roughly one in five of all prescriptions written and dispensed. Those errors include the wrong medications being given, the wrong dose, or delays in getting the patient their medicine.

And while the vast majority of those errors didn’t result in any harm to the patient, a handful of those errors could have legitimately caused harm.

In the United States, the situation is considerably worse. According to a CNBC report from February of 2018, medical errors are the third-leading cause of death in the U.S.