Computerised prescribing systems make it all too easy to give patients sulfadiazine (a treatment for rheumatic fever and toxoplasmosis) instead of sulfasalazine (a treatment for rheumatoid arthritis). Similar dosing and adjacent keyboard letters D and S may exacerbate this. In our region, three patients have experienced this error and in two of the cases it has taken over a year for the patient or their doctors to pick up this error. Prescribers and pharmacists need to be wary of this potential pitfall.
Queen Alexandra Hospital, Portsmouth