Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2021 Feb;87(2):386-394.
doi: 10.1111/bcp.14285. Epub 2020 Apr 20.

The problem of look-alike, sound-alike name errors: Drivers and solutions

Rachel Bryan  1 , Jeffrey K Aronson  2 , Alison Williams  1 , Sue Jordan  1
Affiliations
Free article
Review

The problem of look-alike, sound-alike name errors: Drivers and solutions

Rachel Bryan et al. Br J Clin Pharmacol. 2021 Feb.
Free article

Abstract

Look-alike or sound-alike (LASA) medication names may be mistaken for each other, e.g. mercaptamine and mercaptopurine. If an error of this sort is not intercepted, it can reach the patient and may result in harm. LASA errors occur because of shared linguistic properties between names (phonetic or orthographic), and potential for error is compounded by similar packaging, tablet appearance, tablet strength, route of administration or therapeutic indication. Estimates of prevalence range from 0.00003 to 0.0022% of all prescriptions, 7% of near misses, and between 6.2 and 14.7% of all medication error events. Solutions to LASA errors can target people or systems, and include reducing interruptions or distractions during medication administration, typographic tweaks, such as selective capitalization (Tall Man letters) or boldface, barcoding, and computerized physician order entry.

Keywords: look-alike; medication error; nomenclature; similarity; sound-alike.

PubMed Disclaimer

References

REFERENCES

    1. NaPSIR quarterly data summary: January to March 2018 (individual CSV files), specifically the ‘Harm by Type’ data table. Last accessed 7.2.19 from: https://improvement.nhs.uk/documents/3270/Jan-Mar18_all_tables.zip
    1. Bryan R, Aronson JK, ten-Hacken P, Williams AJ, Jordan S. Patient safety in medication nomenclature: orthographic and semantic properties of international nonproprietary names. PLoS ONE. 2015a;10(12):e0145431.
    1. Shaw KN, Lillis KA, Ruddy RM, et al. Reported medication events in a paediatric emergency research network: sharing to improve patient safety. Emerg Med J. 2013;30(10):815-819.
    1. Bundy DG, Shore AD, Morlock LL, Miller MR. Pediatric vaccination errors: application of the “5 rights” framework to a national error reporting database. Vaccine. 2009;27(29):3890-3896.
    1. Emmerton LM, Rizk MFS. Look-alike and sound-alike medicines: risks and “solutions”. Int J Clin Pharm. 2012;34(1):4-8.

Publication types

Substances

LinkOut - more resources