Misapplication of a drug prescription as a result of various reasons may cause serious, even life-threatening consequences. This case report presents two examples of such situations in which Amicasin was applied instead of the prescribed Ampicillin Sulbactam. The role of the doctor, nurse and the pharmacists in these situations was also discussed. In case one; a one year old boy patient who came to our clinic with complaints of cough was given a prescription of parenteral Ampicilline Sulbactam with a diagnosis of pneumonia. The first three doses were given to the patient in a different health center and when the patient applied to our hospital for the fourth dose, it was realized by the nurse that the medicine the patient was given previously was Amicasin instead of Ampicillin. Consequently, the patient was admitted to the hospital for follow up and treatment with the Amicasin intoxication. In the second case; a 7 months old boy patient who came to our pediatric emergency department with complaints of cough and fever was prescribed parenteral Ampicilline Sulbactam with a diagnosis of pneumonia. The first two doses were given in a different health center and since then the patient had complaints of vomiting. When he came to our hospital, the previously applied medicine was checked and, it was realized that the patient was given Amicasin instead of Ampicillin in the pharmacy. The patient admitted to the hospital for follow up and treatment with the Amicasin intoxication. We conclude that it is very important for doctors to write the prescriptions in a clear and readable way, for pharmacists’ to give the medicines carefully, and for nurses to be very careful during the application process of the medicines.

Keywords: Aminoglycoside, wrong drug, amicasine