Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system

Patient Safety in Surgery
Joerg SchnoorChristoph-Eckhardt Heyde

Abstract

The acronym LASA (look-alike sound-alike) denotes the problem of confusing similar- looking and/or sounding drugs accidentally. The most common causes of medication error jeopardizing patient safety are LASA as well as high workload. A critical incident report of medication errors of opioids for postoperative analgesia by look-alike packaging highlights the LASA aspects in everyday scenarios. A change to a generic brand of medication saved costs of up to 16% per annum. Consequently, confusion of medication incidents occurred due to the similar appearance of the newly introduced generic opioid. Due to consecutive underdosing no life-threatening situation arose out of this LASA based medication error. Current recommendations for the prevention of LASA are quite extensive; still, in a system with a lump sum payment per case not all of these security measures may be feasible. This issue remains to be approached on an individual basis, taking into consideration local set ups as well as financial issues.

References

Jun 3, 2004·Journal of Medical Systems·Adrienne Berman
Oct 29, 2004·The New England Journal of Medicine·Christopher P LandriganCharles A Czeisler
Mar 14, 2009·BMJ : British Medical Journal·Andreas ValentinUNKNOWN Sentinel Events Evaluation (SEE) Study Investigators
May 7, 2010·The New England Journal of Medicine·Eric G PoonTejal K Gandhi
Dec 12, 2012·Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen·Herbert Sommer, Anne Dwenger

❮ Previous
Next ❯

Citations

Jul 21, 2017·Expert Opinion on Drug Safety·Enrique Seoane-VazquezGordon Schiff
Oct 4, 2017·BMJ Quality & Safety·Ken CatchpoleScott T Reeves
Mar 22, 2020·British Journal of Clinical Pharmacology·Rachel BryanSue Jordan
Apr 25, 2019·Thérapie·Frédéric TranchardFabien Despas

❮ Previous
Next ❯

Software Mentioned

LASA
PENTObarbital
PHENObarbital

Related Concepts

Trending Feeds

COVID-19

Coronaviruses encompass a large family of viruses that cause the common cold as well as more serious diseases, such as the ongoing outbreak of coronavirus disease 2019 (COVID-19; formally known as 2019-nCoV). Coronaviruses can spread from animals to humans; symptoms include fever, cough, shortness of breath, and breathing difficulties; in more severe cases, infection can lead to death. This feed covers recent research on COVID-19.

Blastomycosis

Blastomycosis fungal infections spread through inhaling Blastomyces dermatitidis spores. Discover the latest research on blastomycosis fungal infections here.

Nuclear Pore Complex in ALS/FTD

Alterations in nucleocytoplasmic transport, controlled by the nuclear pore complex, may be involved in the pathomechanism underlying multiple neurodegenerative diseases including Amyotrophic Lateral Sclerosis and Frontotemporal Dementia. Here is the latest research on the nuclear pore complex in ALS and FTD.

Applications of Molecular Barcoding

The concept of molecular barcoding is that each original DNA or RNA molecule is attached to a unique sequence barcode. Sequence reads having different barcodes represent different original molecules, while sequence reads having the same barcode are results of PCR duplication from one original molecule. Discover the latest research on molecular barcoding here.

Chronic Fatigue Syndrome

Chronic fatigue syndrome is a disease characterized by unexplained disabling fatigue; the pathology of which is incompletely understood. Discover the latest research on chronic fatigue syndrome here.

Evolution of Pluripotency

Pluripotency refers to the ability of a cell to develop into three primary germ cell layers of the embryo. This feed focuses on the mechanisms that underlie the evolution of pluripotency. Here is the latest research.

Position Effect Variegation

Position Effect Variagation occurs when a gene is inactivated due to its positioning near heterochromatic regions within a chromosome. Discover the latest research on Position Effect Variagation here.

STING Receptor Agonists

Stimulator of IFN genes (STING) are a group of transmembrane proteins that are involved in the induction of type I interferon that is important in the innate immune response. The stimulation of STING has been an active area of research in the treatment of cancer and infectious diseases. Here is the latest research on STING receptor agonists.

Microbicide

Microbicides are products that can be applied to vaginal or rectal mucosal surfaces with the goal of preventing, or at least significantly reducing, the transmission of sexually transmitted infections. Here is the latest research on microbicides.

Related Papers

Journal of Psychiatric Nursing and Mental Health Services
E L Dembicki
Indian Journal of Pharmacology
Hetal D Shah, Megha Shah
© 2021 Meta ULC. All rights reserved