Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

Newspaper/Magazine Article

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

June 3, 2009

ISMP Medication Safety Alert! Acute Care Edition. May 21, 2009;14:1-3.

This article shares results from a survey regarding look-alike or sound-alike (LASA) medication confusion and lists strategies to reduce such errors.

Free full text

Related Resources From the Same Author(s)

Eric Cropp weighs in on the error that sent him to prison.

December 16, 2009

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

November 18, 2009

Shared MDIs: can cross-contamination be avoided?

April 22, 2009

Beware of basal opioid infusions with PCA therapy.

March 25, 2009

Inattentional blindness: what captures your attention?

March 11, 2009

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

November 4, 2009

The absence of a drug–disease interaction alert leads to a child's death.

June 3, 2015

Building a case for medication reconciliation.

May 3, 2006

Challenges with requiring five characters during ADC drug searches via override.

November 3, 2021

Another tragic parenteral nutrition compounding error.

May 11, 2011

Misidentification of alphanumeric symbols in both handwritten and computer-generated information.

July 15, 2009

Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.

May 6, 2009

Fatal outcome after inadvertent injection of topical epinephrine.

April 8, 2009

Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs).

March 4, 2009

How has the current economy affected patient safety?

September 23, 2009

Correct use of inhalers: help patients breathe easier.

July 27, 2016

Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.

May 18, 2016

A clinical reminder about the safe use of insulin vials.

March 6, 2013

Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.

April 3, 2013

Our long journey towards a safety-minded just culture. Part II: where we're going.

October 4, 2006

Keeping patients safe from iatrogenic methadone overdoses.

February 27, 2008

High-reliability organizations (HROs): what they know that we don't (Part I).

July 27, 2005

Medication orders with future start dates: how far away is too far?

July 27, 2022

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

May 30, 2007

Practitioners anticipate punitive action from licensing bodies.

June 1, 2005

Please don't sleep through this wake-up call.

March 27, 2005

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

August 27, 2008

Too many abandon the "second victims" of medical errors.

July 27, 2011

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

Is an indication-based prescribing system in our future?

November 30, 2016

"Use as directed" can cause confusion for both patients and practitioners.

September 14, 2016

What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.

August 24, 2016

ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors.

August 10, 2016

Do not let "Depo-" medications be a depot for mistakes.

April 13, 2016

Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors.

March 9, 2016

Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.

July 13, 2016

Understanding human over-reliance on technology.

September 28, 2016

More can be done to alleviate errors associated with pharmaceutical product labeling and packaging.

May 19, 2021

Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.

June 20, 2018

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

May 31, 2017

Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.

June 19, 2013

Administering a saline flush "site unseen" can lead to a wrong route error.

May 29, 2013

Considering insulin pens for routine hospital use? Consider this...

May 28, 2008

Multiple latent failures align to allow a serious drug interaction to harm a patient.

May 18, 2011

Reporting and second-order problem solving can turn short-term fixes into long-term remedies.

June 1, 2016

Temporarily holding medication orders safely in order to prevent patient harm.

November 1, 2023

Prevent errors during emergency use of hypertonic sodium chloride solutions.

November 17, 2021

Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.

February 24, 2016

ISMP National Vaccine Errors Reporting Program 2017 analysis—part 1 and part 2.

July 18, 2018

November 14, 2007

Just Culture and its critical link to patient safety—part 1 and part 2.

July 25, 2012

A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!

December 4, 2019

Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.

November 13, 2019

Disrespectful behavior in healthcare...have we made any progress in the last decade?

July 17, 2013

Resolving human conflicts when questions about the safety of medical orders arise.

March 26, 2008

USA Today news series: clarifying the issues and embracing community pharmacy safety.

March 12, 2008

ADC survey shows some improvements, but unnecessary risks still exist.

February 6, 2008

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

Pharmaceutical industry and medical device companies: part of the solution?

November 29, 2006

Harmful errors: how will your facility respond?

October 18, 2006

Your attention please... designing effective warnings.

September 6, 2006

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

July 26, 2006

Error-prone conditions that lead to student nurse-related errors.

October 31, 2007

Potassium may no longer be stocked on patient care units, but serious threats still exist!

October 17, 2007

Fluorouracil error ends tragically, but application of lessons learned will save lives.

October 3, 2007

Lack of standard dosing methods contributes to IV errors.

September 5, 2007

Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.

August 15, 2007

Rapid response team activation by patients can mitigate errors.

June 21, 2006

IV potassium given epidurally: getting to the "route" of the problem.

April 19, 2006

If safety is your yardstick, measuring culture from the top down must be a priority.

April 4, 2007

Reducing patient harm from opiates.

March 7, 2007

The five rights: a destination without a map.

February 7, 2007

Safety requires a state of mindfulness.

March 22, 2006

IV vincristine survey shows safety improvements needed.

March 8, 2006

Double key bounce and double keying errors.

January 31, 2006

Fatal misadministration of IV vincristine.

December 14, 2005

Loud wake-up call: unlabeled containers lead to patient’s death.

March 27, 2005

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

March 6, 2005

Learning from errors with the new COVID-19 vaccines.

January 27, 2021

Understanding and managing IV container overfill.

December 4, 2013

Survey shows recession has weakened patient safety net.

January 27, 2010

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

February 23, 2022

Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.

May 12, 2021

A recurring call to action: every healthcare organization needs a medication safety officer!

March 10, 2021

Start the new year off right by preventing these top 10 medication errors and hazards.

January 29, 2020

Speaking up about patient safety requires an observant questioner and a high index of suspicion.

October 30, 2019

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

Are national efforts to reduce drug name confusion paying off?

December 12, 2018

Partnering with families and patient advocates: another line of defense in adverse event surveillance.

August 14, 2019

Independent double checks: worth the effort if used judiciously and properly.

June 19, 2019

Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.

October 17, 2018

Adverse glycemic events and critical emergencies.

December 15, 2021

Maximize benefits of IV workflow management systems by addressing workarounds and errors.

September 20, 2017

Death due to pharmacy compounding error reinforces need for safety focus.

June 28, 2017

Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.

April 12, 2017

Using information from external errors to signal a "clear and present danger."

March 8, 2017

Smart pumps in practice: survey results reveal widespread use, but optimization is challenging.

April 18, 2018

Unreadable barcodes and multiple barcodes on packages can lead to errors.

November 8, 2017

The texting debate: beneficial means of communication or safety and security risk?

July 12, 2017

Related Resources

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions.

October 11, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Taking a closer look at medication errors that involve oxytocin.

June 14, 2023

Medication errors: the year in review: January through December 2021.

January 11, 2023

Investigation of interventions to reduce nurses' medication errors in adult intensive care units: a systematic review.

October 12, 2022

At US hospitals, a drug mix-up is just a few keystrokes away.

May 11, 2022

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

March 30, 2022

Effect of automated unit dose dispensing with barcode scanning on medication administration errors: an uncontrolled before-and-after study.

December 1, 2021

The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: a systematic review.

April 7, 2021

Health information technology-related wrong-patient errors: context is critical.

January 27, 2021

Awareness of human factors in the operating theatres during the COVID-19 pandemic.

January 13, 2021

Annual Perspective

Updates in the Role of Health IT in Patient Safety

February 21, 2020

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

A prescription for enhancing electronic prescribing safety.

December 12, 2018

Toward safer health care: a review strategy of FDA medical device adverse event database to identify and categorize health information technology related events.

November 28, 2018

Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care.

November 14, 2018

Specifications of computerized provider order entry and clinical decision support systems for cancer patients undergoing chemotherapy: a systematic review.

October 10, 2018

People, processes, health IT and accurate patient identification.

October 10, 2018

Errors detected in pediatric oral liquid medication doses prepared in an automated workflow management system.

February 28, 2018

Unreadable barcodes and multiple barcodes on packages can lead to errors.

November 8, 2017

Maximize benefits of IV workflow management systems by addressing workarounds and errors.

September 20, 2017

Tackling disrespectful, unprofessional provider behaviors.

July 13, 2016

Do not let "Depo-" medications be a depot for mistakes.

April 13, 2016

WebM&M Cases

Double Dose at Transfer

May 1, 2012

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

October 5, 2011

Prevalence of medication administration errors in two medical units with automated prescription and dispensing.

September 28, 2011

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

August 31, 2011

Scanner beep only means the barcode has been scanned.

July 13, 2011

Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip).

June 22, 2011

See More About The Topic

Risk Managers

Quality and Safety Professionals

Pharmacy

Audit and Feedback

Communication between Providers