EG Pharmacists Urge Brand Name Prescription Reform After Dispensing Error

Last week, seven-year-old Mecca came down with a cold and a sore throat. She visited her doctor for examination, and was prescribed a nutritional supplement to help with the symptoms. Her family sent a photo of the prescription to a pharmacy in Zahraa al-Maadi for home delivery, and the drug was delivered around 11:30 pm. After ingesting a 6-ml dose of the drug, however, Mecca suffered something akin to paralysis, her mother, Samia, tells Mada Masr. “My daughter was suffering from a simple cold,” says Samia. “But the pharmacist confused the last two letters [of the drugs name] and dispensed an epilepsy medication instead. Samia rushed her daughter to the Poison Control Center, which refused to admit Mecca, as did several hospitals afterward, with all of them telling the mother that, since it had been 24 hours since the medication was administered, she needed to go to the intensive care unit at Demerdash Hospital, where the specialized care unit is located. Mecca remained sick for a day and a half, “no longer able to move her hands, legs or eyes, Samia says. She remained in this condition for four days before eventually recovering. Soon after the life-threatening incident, the family filed a lawsuit against the pharmacy and submitted complaints to the Egyptian Drug Authority — the body responsible for pharmacy inspections — as well as to the Pharmacists Syndicate and the public prosecutor. But professionals working in the pharmacy sector and syndicate officials who spoke to Mada Masr say Mecca’s case is not the first time a patient has faced dangerous consequences as a result of mistakes in interpreting prescriptions. For them, complaints and investigations into each individual incident — while important for establishing liability and holding the responsible party accountable — will fail to address the root cause of the problem or prevent its recurrence, leaving patients exposed to the same danger. They believe the true solution lies in changing prescribing practices: mandating that physicians prescribe medications by their generic, non-proprietary names to reduce the likelihood that pharmacists will confuse the commercial names of popular drugs, a demand that pharmacists have put to the Health Ministry in recent days and which has already been recommended in a 2024 prime ministerial directive. However, doctors have expressed unwillingness to adhere to the recommendation — a stance that several sources who spoke to Mada Masr attribute to the strong financial and professional incentives offered by pharmaceutical companies to doctors, part of marketing arrangements that generate billions in revenue. Mistakes in drug dispensation of the kind that endangered Samia’s daughter are easily made when doctors prescribe drugs by their commercial name, according to two pharmacists who spoke to Mada Masr. A Pharmacists Syndicate official, speaking on condition of anonymity, tells Mada Masr that Mecca would not have been endangered had the generic name been used. The confusion originated due to a confusion between the name of the prescribed drug and a different drug with a similar name, he says. The active ingredient in the first medication, Acetylcysteine, is completely different from the one in the second medication, Risperidone, which is used to treat certain psychiatric and neurological disorders, he explains. A pharmacy manager notes that by contrast the trade name for the prescribed drug, Respidep, is very similar to Risperdal, the brand name of the antipsychotic that was dispensed. Similar incidents have occurred many times,” says the pharmacy manager. “One case that stands out in my memory involved a pharmacist who mistakenly dispensed a neurological medication: the difference between the name written on the prescription and the drug actually dispensed was just two letters. A bare minimum threshold to prevent the recurrence of similar incidents would be to mandate that doctors use generic names, says the manager, who stresses that th