So far, apparently, the Celebrex mix-ups have caused no serious injuries. But Teresa Vasquez's husband, Ramon -- a heart patient from rural west Texas -- was not so lucky. In 1995, according to court documents, Vasquez saw cardiologist Ramachandra Kolluru, who wrote out a prescription for the angina drug, Isordil, to be taken four times a day in doses of 20 milligrams. But to the pharmacist on duty at Albertson's pharmacy in Odessa, Texas, the doctor's scrawl looked like Plendil, a blood pressure medication with a maximum daily dose of 10 milligrams a day.

The pharmacist filled the prescription with Plendil but attached directions with the dosage for Isordil. As a result, Vasquez not only got the wrong drug, but he was directed to take it at eight times the maximum daily dosage. He took it several times, each time complaining to his wife about how poor it made him feel. The day after he began taking it, Vasquez suffered a massive heart attack. He died several days later, leaving his wife and three teenage children.

Experts say such mistakes are frighteningly common, though no accurate numbers are available. An estimated 1.3 million Americans are injured each year due to medication errors, such as getting the wrong dose or the wrong drug, according to the FDA. A study published last year in the medical journal Lancet estimated that between 1983 and 1993, the number of deaths caused by drug errors jumped 250 percent to more than 7,000 a year. How many of these deaths and injuries are due to name confusion? That's not clear -- though the U.S. Pharmacopeia, an industry trade group, estimates that about one-quarter of the 1,500 errors reported to its hot line each year involve mix-ups due to drug names that look or sound alike.

Among the fatal mix-ups reported to the FDA:

• Narcan, used to reverse an overdose of narcotics, and Norcuron, a muscle relaxant used to intubate patients.
• Pitressin, a synthetic hormone sometimes used to control bleeding in the esophagus, and Pitocin, used to induce labor in pregnant women.
• Amiodarane, an anti-arrythmic, and Amrinone, used in congestive heart failure.
• Demerol and Roxanol -- both are narcotic analgesics, but Roxanol is more potent than Demerol.

Richard Chacon of Albuquerque, N.M., was one of the near misses. Chacon had been taking medication for chronic heartburn for many years, but in the summer of 1996, he noticed that the Prilosec pills he usually got looked different. He shrugged it off, figuring he'd been switched to a generic. In fact, he'd been given a prescription for Prozac. Without the protection of the right medication, his heartburn symptoms came roaring back. When he woke up one night with severe chest pain, and felt lightheaded and nauseous, he was rushed to the hospital. Since Chacon had a history of heart problems, including a double bypass procedure several years earlier, doctors were concerned that he was having a new round of cardiac trouble. After several days in the hospital, doctors discovered the error and Chacon was released in good condition.

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