Prevention strategies to identify LASA errors: building and sustaining a culture of patient safety

Abstract

Background: Potential look-alike, sound-alike (LASA) errors in outpatient and inpatient prescriptions have been widely described worldwide. However, most strategies of reducing drug name confusion have been only focused on the processes of prescribing and dispensing, often following local rules. Main text: An illustrative recent example about this topic is given: the antidepressant Brintellix® (vortioxetine) (Takeda Pharmaceuticals USA, Inc.) and the antiplatelet medication Brilinta® (ticagrelor) (AstraZeneca LP). Revision of the initiatives that are currently applied to prevent potential LASA errors in different countries around the world and debate about the emerging strategies that could be implemented in short and mid-term. At present, a common policy worldwide on the authorization of unique names for innovative medicines does not exist. The implication of authorities in topdown strategies and the importance of developing an international health policy on the authorization of unique names for innovative medicines are highlighted in the following piece of opinion. Conclusions: Building and sustaining a culture of patient safety should be considered as a global top-down strategy which involved all the elements in the system (regulatory bodies, manufacturers and suppliers). The precedent established by the FDA in prevention strategies to identify and avoid LASA errors has been extremely important and should lead to international discussion. Coordinated international efforts are urgently needed in this area for the sake of patients' safety.

Medication Error Concept and Reporting Practices in Saudi Arabia: A Multiregional Study Among Healthcare Professionals

“…This error was due to brand name confusion resulting in both prescribing and dispensing errors. 27 Given that tens of thousands of medications are on the market today, the likelihood of making these errors is really high. However, some strategies contribute to reducing these errors, such as having a list of LASA medications in all storage areas and ensuring that LASA medications are stored separately.…”

Reminding staff of diligence during the medication process is not enough to ensure safety: Learning from wrong fluid product selection incidents in the care of critically ill patients

“…3 Triangle of reported latent conditions and active failures in different parts of medication process related to wrong fluid product selection incidents, surrounded by safeguards identified in the narrative descriptions of incident reports (on the left of the triangle) and existing literature (on the right of the triangle). 2 , 3 , 5 , 7 , 10 , 11 , 13 , 20. , 21.…”

“…Thus, developing safe product names and readable labels and barcodes should take place both at national and international levels, between medication safety organizations, manufacturers, regulators and end-users to find solutions to ensure safe identification of the products at all phases of the fluid therapy process. 11 , 20 …”

“…Hospital pharmacies should consider, in addition to prices, safety management in the medicine procurement process by avoiding LASA medicines and favouring barcodes on the primary drug packaging. 30 They could also offer re-packaging and attaching extra stickers on the packaging 20 ; using different typographical strategies (e.g. TALLman Lettering), 20 , 21 and inform healthcare professionals about changes in the formulary.…”

“…30 They could also offer re-packaging and attaching extra stickers on the packaging 20 ; using different typographical strategies (e.g. TALLman Lettering), 20 , 21 and inform healthcare professionals about changes in the formulary. 30…”