Here’s a scary thought: dangerous medication mixups could begin at your doctor’s office. The FDA put out a warning today that they’ve received reports of mixups between similarly-named drugs that do very different things. The FDA urges patients and caregivers to know what the drug they’re supposed to be taking looks like, and alert medical providers if the drug that they receive looks different.

The most prominent example that the FDA cited are the drugs Brintellix and Brilinta. Both are relatively new, and dispensed under their very similar brand names. Brintellix is an antidepressant, and Brilinta is a blood thinner. The FDA knows of 50 incidents where one drug has been dispensed instead of the other, but none yet where a patient has been harmed.

Some mixups occurred when pharmacists made an error, confusing the two drugs. Some others began back in the doctor’s office, when a provider went to type an e-prescription into a computerized physician order entry (CPOE) system. When a physician types “BRI” in to the system, both drugs pop up; all he or she needs to do is pick the wrong one.

The FDA’s advice to patients and caregivers is to know the names of the medicines you’re taking and why you’re taking them. This is important when you actually receive the medication, so you can study the bottle and any guides that the pharmacy has included. These will explain the medication, how to take it, and what conditions it’s normally taken for. If something doesn’t match up, alert the pharmacist.

FDA Drug Safety Communication: FDA warns about prescribing and dispensing errors resulting from brand name confusion with antidepressant Brintellix (vortioxetine) and antiplatelet Brilinta (ticagrelor) [FDA]

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