Abstract
To the Editor. —Pharmaceutical brand name confusion is an important problem. 1 We have encountered an example of such confusion when an order for a Z-Pak was misinterpreted as an order for an ice pack. Zithromax capsules of azithromycin are available as red, opaque, hard-gelatin capsules prepackaged in a blister card of 6 capsules, which is called a Z- Pak. The Z-Pak card includes standard dosing instructions for the patient, which allows physicians to write a prescription for the drug by simply writing the term Z- Pak on the prescription form without including specific dosing instructions. This abbreviated ordering method resulted in the following therapeutic misadventure. A 49-year-old woman was admitted with new onset of pleuritic chest pain and purulent sputum and had a new infiltrate apparent on the chest x-ray film. An order was written in the hospital inpatient chart for a Z-Pak. The order included no specific dosing instructions
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