American Health Packaging voluntarily issued a recall on their ibuprofen lot #142588 and oxcarbazepine lot #142544 due to the inner blister packs being mislabeled. This error could result in patients who need oxcarbazepine, a drug used to treat seizures, receiving ibuprofen instead. Missing a dose of oxcarbazepine could precipitate a seizure in patients who are stable on the drug. Likewise, people needing ibuprofen could receive oxcarbazepine, causing them to experience a number of adverse effects. What measures do you take to reduce the chance for a medication error?
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