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

Patient Safety in Surgery

Christoph-Eckhardt Heyde³  Nils Engelmann⁴  Roberto Frontini²  Christina Rogalski⁵  Joerg Schnoor¹ 

[1] Department of Anesthesia and Intensive Care Medicine, University Hospital Leipzig, Liebigstraße 20, Leipzig, 04103, Germany;Pharmacy, University Hospital Leipzig, Liebigstraße 20, Leipzig, 04103, Germany;Department of Orthopedics, Traumatolgy and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, Leipzig, 04103, Germany;Shining Towers, Mubarak bin Mohammed St, Khalidiyah, Abu Dhabi, UAE;Office of Quality and Risk Management, University Hospital Leipzig, Liebigstraße 20, Leipzig, 04103, Germany

关键词: High work load;    Costs;    Medication error;    LASA;    Look alike-sound alike;    Patient safety;   

Others  :  1151527
DOI  :  10.1186/s13037-014-0047-0

 received in 2014-07-23, accepted in 2014-12-09,  发布年份 2015

【 摘 要 】

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.

【 授权许可】

   
2015 Schnoor et al.; licensee BioMed Central.

【 图 表 】

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