Double Dosing

Nancy Dunn, a 34-year-old patient, was inadvertently taking double the intended dose of fluoxetine due to being prescribed Prozac for major depression and Sarafem for premenstrual dysphoric disorder, not realizing they were the same medication. This led to symptoms such as loss of appetite, nausea, vomiting, diarrhea, and tension, which were resolved within a week after a nurse practitioner advised her to stop taking Prozac. The case highlights the issue of fragmented care and the lack of communication between healthcare providers, as well as the importance of patient and staff education on drug names. The article suggests that patients should provide a complete list of medications, including over-the-counter drugs and supplements, and that healthcare providers should ensure they check both brand and generic names to prevent duplication. The Institute for Safe Medication Practices had issued an alert in July 2002 about the risks of prescribing drugs available under different brand names for different indications.