Practitioners' Reporting News

Dispensing Errors Involving Lamictal and Lamisil

Issued March 15, 2002

The USP Medication Errors Reporting (MER) Program has received multiple reports of medication errors because of confusion between Lamictal® and other drugs with similar proprietary names or generic names. These reports have most frequently cited confusion with the products Lamisil®, lamivudine, Ludiomil®, labetolol, and Lomotil®. Most commonly reported are descriptions of medication dispensing errors involving Lamictal or Lamisil. Either Lamictal was ordered and Lamisil was dispensed or Lamisil was ordered and Lamictal was dispensed. Lamictal, a trade name for lamotrigine, is prescribed in the treatment of seizures. Lamisil, a trade name for terbinafine hydrochloride, is prescribed in the treatment of fungal infections.

In one report, Lamictal 25 mg was dispensed with a label on the container indicating it contained "Lamisil." According to the reporter, the patient was also given printed information for Lamisil. The patient took the Lamictal for a month before discovering the error when a second pharmacy refilled the prescription. The refill was dispensed in the manufacturer's container and the patient noticed that the tablets were different from those received with the original prescription. Fortunately, no adverse effects were reported.

In a second report, a female patient received 25-mg tablets of Lamictal (anticonvulsant) instead of 250-mg tablets of Lamisil (antifungal). The patient took the Lamictal for a month before discovering that she received the wrong medication. While taking the Lamictal, the patient experienced an elevated blood pressure, itching, and sternal pain.

In a third report, Lamictal 200-mg tablets were dispensed for a pediatric patient with a prescription for Lamisil 250-mg tablets. The patient took the Lamictal for nine days resulting in a five-day hospital stay. The hospital stay included spending two days in an intensive care unit followed by three days in a patient care unit.

In a fourth report, Lamisil 250 mg was dispensed to a patient with a prescription for Lamictal 25 mg, two tablets twice a day. The patient's mother detected the error before any of the Lamisil was administered to the patient and the incorrect medication was returned to the pharmacy.

To reduce the risk of dispensing errors caused by name confusions between Lamictal and other products, GlaxoSmithKline, the manufacturer for Lamictal, announced a redesign of the product's container label. The redesign highlights the "ICTAL" portion of the product's trade name and a caution printed on the label to "Verify Product Dispensed." In addition, the redesign includes the use of different colored labels to indicate different tablet strengths.

To help reduce dispensing errors with medications, The National Coordinating Council for Medication Error Reporting and Prevention provides a list of recommendations on its Web site at www.nccmerp.org. To access the council's "Recommendations for Avoiding Error-Prone Aspects of Dispensing Medications", select Council Recommendations on the Web site sidebar.


Readers are advised that official USP cautions and warnings for drugs appear in the USP–NF or USP DI. Unless otherwise indicated, any advice or opinions expressed herein reflect solely the judgment of USP staff. Such statements are intended for further consideration and evaluation and may or may not be applicable to a particular practice. The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices.