Alert Issued in Mislabeling of Drug Packages

Because of a potentially fatal mix-up in the packaging of a prescription drug, state health officials issued a warning Thursday to patients who received what they believed to be anti-infection tablets labeled “metronidazole” from two Orange County clinics.

As a result of the packaging error, a number of patients at AmeriCare 1 clinics in Orange and La Palma, who should have received metronidazole received instead an anti-diabetes medication that can cause low blood sugar, coma and death when taken in dosages recommended for the anti-infection drug. All but six of the prescriptions have been accounted for and the improperly labeled medications recovered.

Dr. Kenneth W. Kizer, state health services director, urged patients who obtained prescriptions labeled “metronidazole 250 mg” from the two clinics to contact their physicians and check the labels carefully before taking the drug. The tablets are dispensed in amber colored boxes, 2 1/2 inches by 1 1/2 inches by 1/2 inch. The lot number on those boxes is 2979707, with the expiration dates of 5-86 or 6-86. The pills are stamped with the code Z2979.

Prescription Is Traced

The tablets are actually the anti-diabetic drug tolazamide.

Health officials discovered the mix-up after a woman was admitted to a Southern California hospital in a coma earlier in the week. The officials, who said she is now recovering, were able to determine that she had taken the wrong medication and traced the prescription back to the clinic.

The state Department of Health Services said the error evidently occurred at the point where the medicines were packaged. Michael O’Neil, president of U.S. Medical Enterprises (parent firm of AmeriCare 1) identified the packager as Med-Pack Pharmaceuticals of Huntington Beach.

Health officials say that the drug-packaging company shipped about 1,000 mislabeled tablets to the AmeriCare Clinics, which has recovered all but six of the small boxes, containing either eight or 21 scored white tablets.

The patients who have received the mislabeled pills are most likely women, since the drug metronidazole is most frequently used to treat vaginal yeast infections.