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Published in: Patient Safety in Surgery 1/2015

Open Access 01-12-2015 | Short report

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

Authors: Joerg Schnoor, Christina Rogalski, Roberto Frontini, Nils Engelmann, Christoph-Eckhardt Heyde

Published in: Patient Safety in Surgery | Issue 1/2015

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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.
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Metadata
Title
Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system
Authors
Joerg Schnoor
Christina Rogalski
Roberto Frontini
Nils Engelmann
Christoph-Eckhardt Heyde
Publication date
01-12-2015
Publisher
BioMed Central
Published in
Patient Safety in Surgery / Issue 1/2015
Electronic ISSN: 1754-9493
DOI
https://doi.org/10.1186/s13037-014-0047-0

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