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. 2015 Mar 13:9:12.
doi: 10.1186/s13037-014-0047-0. eCollection 2015.

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

Joerg Schnoor  1 , Christina Rogalski  2 , Roberto Frontini  3 , Nils Engelmann  4 , Christoph-Eckhardt Heyde  5
Affiliations

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

Joerg Schnoor et al. Patient Saf Surg. .

Abstract

Background: 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.

Case presentation: 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.

Conclusions: 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.

Keywords: Costs; High work load; LASA; Look alike-sound alike; Medication error; Patient safety.

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Figures

Figure 1
Figure 1
Medication boxes of Piritramid-hameln (Hameln, Germany) with 2×5 vials ad 2 ml-vials (15 mg Piritramid) and 1 ml-vials (7,5 mg Piritramid), respectively.
Figure 2
Figure 2
Pharmacy dispensing of Dipidolor™- and Piritramid-vials in 2010–2012.
Figure 3
Figure 3
Pharmacy dispensing of Piritramid-packs with 10 vials (7,5 mg in 1 ml; 15 mg in 2 ml) per month in 2012.
See this image and copyright information in PMC

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