Hargett N A, Ritch R, Mardirossian J, Kass M A, Podos S M
Am J Ophthalmol. 1977 Oct;84(4):580-3. doi: 10.1016/0002-9394(77)90456-1.
In three cases acetohexamide (Dymelor), an oral hypoglycemic agent, was mistakenly given to patients instead of acetazolamide (Diamox), which had been prescribed for their glaucoma. A number of similarities, including the fact that both medications are 250-mg white tablets, with similar generic and brand names which are generically repackaged medications juxtaposed on the pharmacist's shelf, predispose to the inadvertent substitution of one medication for the other. In one instance a systemic hypoglycemic reaction resulting in head trauma and confusion ended in an emegency hospital admission following the substitution of acetohexamide for acetazolamide.
有三例患者，原本因青光眼而被处方使用乙酰唑胺（醋氮酰胺），却被误给予了口服降糖药醋磺己脲（甲磺氮卓脲）。这两种药物存在诸多相似之处，包括都是250毫克的白色片剂，通用名和商品名相似，且在药剂师的货架上是相邻摆放的重新包装的仿制药，这些因素都容易导致一种药物被无意地替换为另一种药物。在其中一例中，用醋磺己脲替换乙酰唑胺后，引发了全身性低血糖反应，导致头部受伤和意识混乱，最终患者被紧急送往医院。
