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Reporting a Medication Error

Mix-Ups With a Medicine Used to Treat Infertility

Published October 11, 2023

Clomid (clomiphene) is a prescription medicine used to treat infertility in women. It works by increasing hormones that help develop and release an egg from the ovary, also known as ovulation. The medicine’s generic name, clomiphene, sounds and looks very similar to the generic name of another medicine, clomipramine (Anafranil),which has led to mix-ups. Clomipramine is an antidepressant used to treat obsessive-compulsive disorder.

Recently, we received a report from a woman who was prescribed clomiphene with instructions to take two tablets every evening for five consecutive days. The woman picked up the prescription from her local pharmacy and realized the medicine name on the prescription label was not what she expected. The name clomipramine was on the label. Fortunately, she recognized the mistake and returned it to the pharmacy and was then given the correct medicine.  

In another case, a doctor intended to prescribe clomiphene 50 mg with instructions to take two tablets by mouth daily for five days. By mistake, the doctor sent a prescription for clomipramine 50 mg with instructions to take two tablets once a day for five days. The pharmacist began to fill the order for clomipramine and placed the medicine in the prescription bottle. However, the dose and instructions the doctor provided for clomipramine seemed unusual. So, the pharmacist called the doctor to confirm. The doctor informed the pharmacist that the prescription should have been for clomiphene, not clomipramine. The pharmacist corrected the drug name on the label but never changed the medicine that had already been put in the container. The prescription was dispensed with clomipramine tablets in a container labeled clomiphene. Luckily the woman recognized the tablets looked different than those she had before and returned them to the pharmacy before taking the incorrect medicine.

Over the years, we have received multiple reports involving mix-ups with these two medicines. In addition to the drug names sounding and looking alike, both medicines are available (and dosed) in similar strengths (e.g., 50 mg). All of these similarities increase the chance of a mix-up.

Clomiphene has also been mixed up with other medicines that begin with the same letters. For example, in a recent report, a woman stated that her prescription for clomiphene was filled with clonazepam, a medicine used to treat panic and anxiety disorders. The container was labeled clomiphene; however, the tablets looked different than what she had received in the past. The tablets were later identified as clonazepam.

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